Employee and Non-Medicare Retiree/Survivor Health Plan Changes Effective July 1, 2014
BENEFIT CHANGES RELATED TO FEDERAL HEALTH CARE REFORM AND MENTAL HEALTH PARITY
Increased coverage for the following benefits; these benefits will be standardized across all plans:
- No dollar limit on wigs needed for cancer, leukemia, alopecia areata, alopecia totalis or permanent hair loss due to injury; restrictions may apply
- No dollar limit on low-protein foods for specified complex medical conditions
- No dollar limit on medically necessary Early Intervention Services (infant to age 3)
- No dollar limit on in-home dialysis medical supplies, drugs and equipment
- No dollar limit on speech therapy: visit maximums apply
- $5,000 per person/$10,000 per family in-network out-of-pocket maximum: out-of-pocket maximum will apply to medical and mental health/substance abuse costs, but will not apply to prescription drug costs for Harvard Independence and Primary Choice, Tufts Navigator and Spirit, and UniCare Basic, Community Choice and PLUS. Out-of-pocket maximum will apply to medical, mental health/substance abuse, and prescription drug costs for Fallon Direct and Select Care, Health New England and Neighborhood Health Plan.
OTHER HEALTH PLAN BENEFIT CHANGES
FALLON HEALTH PLAN DIRECT AND SELECT CARE
ItFits Health Club Reimbursement Benefit expanded to include one three-month gym membership reimbursement per subscriber to YMCA/YWCA; one 5-month Weight Watchers Monthly Pass reimbursement per subscriber.
NEIGHBORHOOD HEALTH PLAN
PCP Copay: In keeping with the GIC’s efforts to encourage care coordination by Primary Care Providers (PCPs), PCPs will no longer be tiered and the copay will be $20 per visit.
Outpatient Mental Health/Substance Abuse Copay: $20 per visit
TUFTS HEALTH PLAN NAVIGATOR AND SPIRIT
Inpatient Hospital Care: Tufts Health Plan will no longer tier hospitals by different types of services. Hospitals will be tiered for all services combined based on quality and/or cost.
UNICARE INDEMNITY PLAN BASIC, COMMUNITY CHOICE, AND PLUS
Certain Injectable and Infused Specialty Drugs for conditions such as arthritis, multiple sclerosis and immune diseases will be dispensed and managed through CVS Caremark Specialty Pharmacy and will be excluded from the medical benefit. This provision does not apply to infused chemotherapy agents.
UNICARE INDEMNITY PLAN PLUS
PCP Copay: Members will pay a lower copay if they visit a Centered Care PCP: $15 per visit
This information provided by the Group Insurance Commission.