PEBP offers a general wellness benefit in the form of an annual maximum benefit of $2,500 per covered individual.  The wellness benefit covers routine wellcare services such as physicals, screening laboratory and radiology tests, immunizations, colonoscopies, hearing test and skin cancer screenings..  Participants should consult with their physicians to determine what their individual screening needs might be. This benefit is only available when participating PPO providers are used.  Preventive screening benefits are only for wellcare. Any test or procedure done that is related to a known or present condition will be considered as a regular medical claim and processed accordingly.  Once the annual wellness benefit is exhausted, the participant will be responsible for subsequent charges.

Wellness services are payable up to a maximum annual benefit of $2500 per covered participant and each covered dependent.

It is the patient’s responsibility to inform their physician and their physician’s billing staff of their wellness benefits.  The physician however, makes the determination regarding the purpose of the visit, i.e. was the visit for screening purposes only or a follow up visit for a known medical condition.

Yes.  You will however, be responsible for any billed amounts that exceed the Plan’s usual and customary allowance.  Information regarding the usual and customary allowance can be obtained from UMR.

The Cardiac Wellness Program (CWP) is a pilot program and is available to participants of the self-funded PPO plan and their covered dependents.  Participation in the CWP is by invitation only while the effectiveness of the pilot program is being evaluated.  The CWP provides additional coverage for some medical services that may not be covered under the current wellness benefit.  The CWP also applies wellness benefits to medical services rendered for a known cardiac related issue.

Colonoscopies performed for screening purposes are covered under the wellness benefit. However, unless determined to be medically necessary by UMR and PEBP’s Utilization Management Company (APS Healthcare), virtual colonoscopies are not covered under any circumstances under the PEBP PPO plan.

Colonoscopies are not covered under the wellness benefit when you have been previously diagnosed and treated for a medical condition, e.g. colon cancer, colon polyps and  the purpose of the colonoscopy is to follow up on that previously diagnosed and treated condition.

What should I tell my doctor’s office when I’m scheduling my colonoscopy about my wellness benefit?

If your colonoscopy is for screening purposes, you should tell your doctor’s office that you are scheduling a routine screening colonoscopy. If you are scheduling a follow up colonoscopy because of a previously diagnosed and treated medical condition, your claim will be billed with a medical diagnosis and considered under the standard medical benefits subject to the annual deductible, copayments, coinsurance and plan requirements.

UMR cannot disclose to you, the diagnosis submitted by your physician.  UMR can inform you if the bill submitted by your physician did not indicate a routine screening colonoscopy.  If you disagree with the outcome of your claim and would like more information regarding the information submitted by your physician, you should contact your physician’s office.

Yes

Yes

You may qualify for premium-free Medicare Part A at age 65 if you:

·         Receive or are eligible to receive Social Security benefits; or 

·         Receive or are eligible to receive railroad retirement benefits; or 

·         You or your spouse (living or deceased, including divorced spouses) worked 10 years (40 quarters) in Social Security or Medicare covered employment; or

·         You are the dependent parent of someone who worked long enough in a job where Medicare taxes were paid and you meet the requirements of the Social Security Disability Program;  

·         Other conditions may also allow you to qualify for premium-free Medicare Part A. To learn more contact Social Security at 1-800-772-1213.

When you first become eligible for hospital insurance (Part A), you will have a seven-month period (your initial enrollment period) in which to sign up for medical insurance (Part B). A delay on your part will cause a delay in coverage and result in higher premiums. If you are eligible at age 65, your initial enrollment period begins three months before your 65th birthday, includes the month you turn age 65 and ends three months after that birthday.  If you are still working at age 65, please refer to the Special enrollment period for working individuals.

At age 65 if you are still working and have coverage under an employer group health plan, (i.e., PEBP), you may qualify for a special enrollment period in which to sign up for Medicare Part B. This means that you may delay your enrollment in Medicare Part B (until you stop working) without having to wait for the general enrollment period and pay the 10 percent premium surcharge for late enrollment. For information on Medicare enrollment dates and benefits, contact the CMS at 800-633-4227 or visit their web site at www.medicare.gov.

You will pay a premium each month for Part B. Most people pay the standard premium amount which is $96.40 in 2009. However, your monthly premium will be higher if you meet certain income levels. Contact Social Security at

1-800-772-1213 to determine your monthly premium cost.

If you do not enroll in Medicare Part B when eligible (retiree or retiree’s covered spouse, aged 65), PEBP will assume that you have Medicare Part B. That assumption would mean that PEBP would be the secondary payer to eligible medical expenses ordinarily covered by Medicare Part B.  You would be the primary payer for medical services provided on your behalf that would ordinarily be covered by Medicare Part B. In other words, you would pay 80% as the primary and PEBP would pay 20% as the secondary payer.

At age 65, if you are enrolled in the Self-funded PPO Plan will need to enroll in Medicare Part A if you qualify for the premium-free Part A coverage.  You will also need to purchase Medicare Part B.  Your Medicare coverage (Parts A and B) would then become your primary insurance and PEBP would become the secondary payer. 

PEBP would remain as the primary payer for eligible hospital expenses ordinarily covered by Medicare Part A.

Once you become entitled to Medicare, you will need to submit a copy of your Medicare card to the PEBP office. No other action is necessary.  That is, unless you wish to change your health plan from the regular HMO plan to that carrier’s Medicare Advantage plan.  In that case, you would be required to complete the Retiree Benefit Enrollment and Change Form and the applicable Medicare Advantage plan’s enrollment application.