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If you have Medicare Part A and Part B coverage and you do not have Part D prescription drug coverage, the Major Medical Medicare Supplement Plan is available to you. This Plan provides an additional level of protection for hospital and medical expenses after Medicare pays.
You are automatically covered for prescription drug benefits when you enroll in the Major Medical Medicare Supplement Plan. UnitedHealthcare underwrites the Major Medical Medicare Supplement Plan and Medco administers the prescription drug plan.
Highlights
Your Major Medical Medicare Supplement Plan Benefits … |
… Are Available to Retirees and Eligible Spouses Who are at Least Age 65 and are Covered Under Medicare Part A and Part B, but not Part D. … Provide coverage for certain eligible medical expenses which no Medicare benefits, or limited Medicare benefits, are payable. … Pay benefits for covered medical expenses which are more than the amount payable for the same expenses under Medicare Part A or B. Medicare Part A and B are primary benefits to this Plan. |
What happens to your benefits when ... |
Your Prescription Drug Benefits ... |
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… Provide Comprehensive Drug coverage and Do Not Coordinate With Medicare Part D Prescription Drug Benefits. … Allow You the Flexibility to Use a Network Pharmacy or any Pharmacy You Choose
… Offer a Convenient Home Delivery Option
Have your ID card and your refill bottle with the prescription information ready. |
How the Major Medical Medicare Supplement Plan Works
Medicare Part A and Part B benefits are primary to this Plan's benefits for Medicare-eligible Retirees and their Eligible Dependents. This means Medicare pays benefits first. Then this Plan considers eligible expenses which are more than the amount payable for the same medical expenses under Medicare Part A or Part B.
You must enroll when first eligible, and maintain coverage, under both Medicare Part A and Part B to be eligible for coverage in this Plan.
If you enroll in a Medicare Part D prescription drug plan, your medical and prescription drug coverage under this Plan will be cancelled and you cannot re-enroll at a later time. These eligibility rules apply to Retirees and to an eligible spouse of a Retiree.
If you or your spouse cancel coverage or lose coverage for any reason (including enrolling in Medicare Part D), there is no future opportunity to re-enroll in this Plan.
In order for a spouse to participate in this Plan, the Retiree must participate.
You must elect coverage when you are first eligible. If you do not, or you elect and later cancel coverage, neither you nor your spouse can later enroll.
Annual Deductible - Medical Benefits
Each covered person must first pay the Annual Deductible under the Major Medical Medicare Supplement Plan.
When Medicare applies the Part A or Part B deuctible to a medical claim, this plan also applies the same amount toward this Plan's Annual Deductible. This Plan's Annual Deductible for medical expenses will be met when any eligible credits from Medicare Part A or Part B plus any out-of-pocket expenses you pay equal the Annual Deductible.
Medical benefits are subject to satisfaction of the Annual Deductible and payment of coinsurance listed under the coinsurance column in the Summary of Benefits.
The terms "Annual Deductible," "Retiree" and "Eligible Dependents" are defined in the Glossary.
Lifetime Maximum Benefit
Once plan coverage begins, the Major Medical Medicare Supplement Plan will pay up to $75,000 in benefits for each covered person during the rest of his or her lifetime. This maximum also includes benefits paid under the prescription drug program.
General Expenses Not Covered
The Major Medical Medicare Supplement Plan does not cover some expenses. These include, but are not limited to, charges for:
- routine health checkups
- treatment in a skilled nursing facility, nursing home, convalescent home, or similar institution
- dental services, except for treatment by a physician, dentist, or dental surgeon as a result of accidental injury to natural teeth and received within six months of the accident while insured under the Plan
- cosmetic surgery or treatment except as required to correct damage caused by an accident while insured
- smoking cessation programs and treatment of nicotine addiction
- acupressure, hypnotism, rolfing, massage therapy, acupuncture, and other forms of alternative treatment
- repair, replacement or duplicate prosthetic or durable medical equipment
- experimental or investigational services and unproven services are excluded. The fact that an experimental or investigational service or an unproven service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in benefits if the procedure is considered to be experimental or investigational or unproven in the treatment of that particular condition
- health services received after the date your coverage under the plan ends, including health services for medical conditions arising before the date your coverage under the Plan ends
- health services provided in a foreign country, unless required as emergency health services. An emergency medical condition is one that manifests itself by symptoms of sufficient severity and potentially results in placing the person’s life in serious jeopardy, serious impairment of bodily functions or dysfunction of any bodily organ or part
- eyeglasses, hearing aids and related examinations
- treatment of any injury or sickness caused by an act of war
- services which do not require payment
- treatment received before the effective date of coverage under this Plan
- services to the extent they are covered by any government plan
- services prohibited by law or regulation of any government
- treatments for which automobile no-fault benefits are payable
- health services and associated expenses for the surgical treatment and non-surgical medical treatment of obesity, including morbid obesity
- expenses above Reasonable and Customary Charges.
“Reasonable and Customary Charge” is defined in the Glossary.
Filing Medical Claims
The coordination of payment between Medicare and this Plan can be set up under the Medicare Crossover arrangement. If you elect the Medicare Crossover arrangement, Medicare will automatically file claims information with UnitedHealthcare, the insurance company. Medicare Crossover forms are available in the Benefit Plans Office. However, for expenses (such as ambulance service) which are not considered eligible under Medicare, you must file a claim to receive benefits.
Claims for reimbursement of eligible expenses should be submitted within 90 days from the date of service. If this information is not received within 1 year and 90 days from the date of service, the claim will be denied.
Claims for prescription drug expenses should be filed under the prescription drug program.
If you need assistance in filing a claim, or if you have questions relating to plan coverage, call UnitedHealthcare at 1-800-436-7295.
Other Important Information
Annual Deductibles
To help you meet your annual deductibles, the Plan has the following features:
First Year Credit – When you first become covered under the Major Medical Medicare Supplement Plan, you will receive credit toward your deductible for any deductible expenses you have met under your current Company medical coverage during the same year.
Three-Month Carryover – If you or your covered spouse do not meet the Major Medical Medicare Supplement Plan deductible by the end of the calendar year, any expenses incurred during the last three months of the calendar year may be "carried over" and applied to the following year’s plan deductible.
Common Accident – Only one deductible applies to all eligible medical expenses resulting from an accident in which you and your covered spouse are injured.
Coordination of Benefits
The Plan pays eligible expenses after Medicare has paid. The Major Medical Medicare Supplement Plan also has a coordination of benefits provision that is designed to prevent duplication of payments when you or your covered spouse can collect benefits from another coverage plan.
Under this provision, when coverage is provided by both the Company and another coverage plan, you or your covered spouse can receive up to a total of 100% of total allowable expenses from both plans – but 100% is the maximum.
Under this provision, there are order of benefit determination rules which determine whether this Plan is a “primary coverage plan” or a “secondary coverage plan” when compared to another coverage plan. In general, the primary coverage plan pays as if the secondary coverage plan did not exist. When the Plan is secondary, it pays after those of another coverage plan, and eligible expenses may be reduced because of the allowable expenses paid by the primary coverage plan.
Coordination of benefits under this Plan excludes individual or family insurance, unless permitted by law.
Subrogation and Refund of Expenses
In summary, subrogation under the Plan is the substitution of one person or entity in the place of another with reference to a lawful claim, demand or right. The Plan shall be subrogated to and shall succeed to all rights of recovery, under any legal theory of any type, for the reasonable value of services and benefits provided under this Plan to you from:
- third parties, including any person alleged to have caused you to suffer injuries or damages;
- your employer;
or
- any person or entity obligated to provide benefits or payments to covered persons, including benefits or payments for underinsured or uninsured motorist protection (these third parties and persons or entities are collectively referred to as "Third Parties").
Summary of Benefits
Major Medical Medicare Supplement Plan |
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You pay… |
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Annual Deductible |
$100 / individual |
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Maximum Lifetime Benefit Per Person |
$75,000 |
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Service |
Your Coinsurance After Annual Deductible |
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Medical Services in a Physician's Office |
20% of Eligible Expenses |
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Allergy Services in a Physician's Office |
20% of Eligible Expenses |
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Professional Fees for Surgical and Medical Services |
20% of Eligible Expenses |
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Inpatient Hospital and Related Health Services |
20% of Eligible Expenses |
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Outpatient Emergency Health Services |
20% of Eligible Expenses |
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Urgent Care Center |
20% of Eligible Expenses |
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Outpatient Surgery, Diagnostic and Therapeutic Services |
20% of Eligible Expenses |
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Mental Health and Substance Abuse Services
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20% of Eligible Expenses |
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Home Health Agency Services |
20% of Eligible Expenses |
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Hospice Care |
20% of Eligible Expenses |
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Ambulance Services (emergency only to nearest hospital) |
20% of Eligible Expenses |
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Accident-related Dental Services |
20% of Eligible Expenses |
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Prosthetic Devices and Durable Medical Equipment |
20% of Eligible Expenses |
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Rehabilitation Services – Inpatient or Outpatient (Includes physical therapy, occupational therapy, speech therapy, and cardiac/pulmonary rehabilitation) |
20% of Eligible Expenses |
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Reconstructive Surgery |
20% of Eligible Expenses |
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Health Services for the Treatment of Diabetes |
20% of Eligible Expenses |
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Bone Mass Measurement |
20% of Eligible Expenses |
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Prescription Drugs, administered by Medco |
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Service |
You pay… |
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Retail Pharmacy |
$150 deductible per calendar year |
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You pay 50% of the cost (after the $150 calendar year deductible) for out-of-network claims |
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Mail Order – Home Delivery |
Generic: $15 copayment |
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Out-of-network claims are not covered |
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Administrative Information |