Insurance Trust for Delta Retirees 2013 Medical Benefit Plan

Insurance Trust for Delta Retirees 2013 Medical Benefit Plan

UnitedHealthcare Senior Supplement Plan

Your Plan Explained

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The Insurance Trust for Delta Retirees has chosen to offer its Medicare-eligible retirees the UnitedHealthcare Senior Supplement plan. This plan provides the flexibility needed to keep health care decisions in your hands, including what doctors to visit. Benefits are provided for covered health services received from any doctor or other licensed medical professional that accepts Medicare.

Medical Benefits Exclusion: This plan does not cover: any expense that is not a Medicare Eligible Expense or beyond the limits imposed by Medicare for such expenses or excluded by name or specific description by Medicare, except as specifically provided in the policy; any portion of a covered expense to the extent paid by Medicare; benefits payable under one benefit to the policy to the extent covered under another benefit of the policy; or expenses incurred after coverage terminates. The summary of program benefits described here is for illustrative purposes only. In case of differences or errors, the Group Policy governs.

The Senior Supplement plan explained.The Senior Supplement plan is a group medical plan for Medicare-eligible retirees and is available only through a plan sponsor, such as the Trust. You must be enrolled in Medicare Parts A and B to be eligible to enroll in this plan. If you’re not sure you are enrolled in Medicare Parts A and B, you can check with your local Social Security office.

The Senior Supplement plan acts as a supplement to your existing Medicare Part A (hospital) and Part B (doctor and outpatient care) coverage, helping to pay for some or all of the costs that Original Medicare does not cover.

The Senior Supplement plan is different from Medicare Advantage plans. With Medicare Advantage plans members receive their Medicare Part A and Part B benefits through the plan and use of a provider network may be required. With the Trust’s Senior Supplement plan, eligible Part A and Part B benefits are paid by Original Medicare first as the primary payor. Next, Medicare submits any charges remaining directly to the Trust’s insurance carrier, UnitedHealthcare, as the secondary payor. You may receive services from any doctor or licensed medical professional that accepts Medicare.

Introducing the Insurance Trust for Delta Retirees Senior Supplement plan insured by UnitedHealthcare.

Prescription drug coverage. The Insurance Trust for Delta Retirees has also selected the UnitedHealthcare® MedicareRx for Groups (PDP) plan for your prescription drug coverage. When you enroll in the Senior Supplement plan, you will be automatically enrolled in the prescription drug plan. You can find additional information on the UnitedHealthcare MedicareRx for Groups plan in this enrollment kit.

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Summary of Senior Supplement Coverage Part A Services

Medicare Pays Trust Plan Pays You Pay

Hospital Confinement Benefit: A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. Semi-private room and board, general nursing and miscellaneous services and supplies:

First 60 days All but Part A deductible 100% of the Part A deductible $0

61st through 90th dayMedicare Allowable Amount

Except for Published Copayment Per Day Rate

100% of Balance Remaining after Medicare $0




365 lifetime additional reserve days $0 100% of Balance Remaining after Medicare $0

Beyond 365 days $0 $0 All charges

Skilled Nursing Facility Care: A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. Semi-private room and board, general nursing and miscellaneous services and supplies:

First 20 days All approved amounts $0 $0




101st through 365th day $0 $0 All charges

Beyond 365 days $0 $0 All charges

Hospice care, pain relief, symptom management, and support services for the terminally ill:

As long as a physician certifies the need

All costs, but limited coinsurance for

outpatient drugs and inpatient respite care

50% coinsurance 50% coinsurance

Blood, hospital confinement, and outpatient medical expenses when furnished by a hospital or skilled nursing facility during a covered stay:

First 3 pints $0 100% $0

Additional amounts 100% $0 $0

Introducing the Insurance Trust for Delta Retirees Senior Supplement plan insured by UnitedHealthcare.

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Part B Services

A $300 calendar year deductible must be satisfied by you before the Plan pays Medicare Part B outpatient benefits. Deductible applies to all benefits except Hospital Confinement, Skilled Nursing Care and Hospice Care. Only covered benefits will count toward meeting the deductible.

A $1,500 Annual Out-of-Pocket Maximum applies to the plan. Amounts you incur for covered expenses, such as your calendar year deductible and any Part B coinsurance, will count toward meeting the annual out-of-pocket maximum for this plan.


Outpatient Medical Expenses: In or out of the hospital and outpatient hospital treatment, such as physician services, inpatient and outpatient medical and surgical services, physical and speech therapy, diagnostic tests, durable medical equipment:

Medicare Part B Deductible $0 0% 100%

Remainder of Medicare-approved amounts Generally1 80%

50% of the 20% coinsurance until your out-of-pocket expenses reach $1,500

(including the calendar year deductible of $300) then the Trust Plan pays the full 20%

50% of the 20% coinsurance until your

out-of-pocket expenses reach $1,500 then

you pay 0%

Clinical laboratory services, blood tests, etc. Generally1 80%100% of Balance Remaining

after Medicare$0

Part B Excess Charges covers the difference between the actual Medicare Part B charge as billed and the Medicare-approved Part B charge

$0 100% $0

1Medicare handles claims for Mental Illness and Alcoholism treatment differently.

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Foreign Travel Emergency Medically Necessary services during the first 60 days of each trip outside the United States

$0 80% coinsurance up to a maximum benefit of $100,000 per lifetime

$250 deductible per year. 20% coinsurance (to a lifetime maximum

of $100,000, 100% thereafter)

Pap Test & Pelvic Exam (includes clinical breast exam) once per calendar year

100% Every 24 Months

100% of balance if not covered by Medicare $0

Prostate Cancer Screening once per calendar year

For men 45 and older, 100% $0 $0

Mammogram Screening once per calendar year 100% $0 $0

Annual Routine Physical Exam (not covered by Medicare) $0

100% In addition to Medicare’s annual wellness exam, the plan covers a routine physical so members can have a more

expanded visit with their physician.This includes a comprehensive physical examination and evaluation of status of

chronic diseases

$0

Four great reasons to choose the Insurance Trust’s Senior Supplement Plan insured through UnitedHealthcare.

Help controlling your health care costs This plan covers many of your out-of-pocket expenses by covering many of the costs above what

Original Medicare covers.

Flexibility — no networks We understand that your choice of doctors, hospitals and other health care providers is important.

With this plan, you have the freedom to choose any doctor or hospital anywhere in the country that accepts Medicare.

Additional programs that make a difference Additional programs that contribute to your health and wellness are available with this plan.

Some examples include a fitness program, health and well-being programs, a hearing aid program and emergency travel assistance.

Retiree-focused, dedicated Customer Service UnitedHealthcare has created a dedicated customer service team that has been trained on your

specific group-sponsored plans. With one simple phone call, you can get answers to all your medical and prescription drug benefit questions. Now that’s convenience.

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Other Services

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SilverSneakers® Fitness Program – Choose a fitness center from more than 11,000 participating locations. If you are unable to travel to a SilverSneakers fitness center, you can register for SilverSneakers Steps. This personalized program provides resistance bands, exercise DVDs, and how-to materials to help you measure, track, and increase your activity. This is a great program to help you stay active and enjoy your retirement.

OptumizeMe® – is a mobile application for iPhone and Android smartphone users that helps people pursue their health goals through their own online social networks, like Facebook, where they can track their progress and issue fun fitness challenges to their friends, family and coworkers.

Additional programs.

Get help for hearing loss. It’s easier than ever to take control of your hearing and your health. As a member of this plan you can access high quality, digital hearing devices at reduced prices through hi HealthInnovations, potentially saving you thousands of dollars.

Emergency Travel Assistance Program – FrontierMEDEX provides 24-hour travel, medical and security assistance to you and your dependents while traveling 100 miles or more away from your home or internationally.

Online Will Program – You have access to a state-specific Will program that will help you create your or a loved one’s Will online, in a private and secure environment.

Identity Theft Protection – You have quick and affordable help when your identity has been stolen. Fraud resolution specialists will help you restore your identity, credit and peace of mind. Note: Additional information on how to access and use these benefits will be available upon enrollment.

Additional protection for added peace of mind.

Stay active. Make your quality of life the best it can be.

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What happens after you enroll?

1. Look for your member ID card. Within 4 to 6 weeks, you will receive your new ID card.

2. Review your welcome kit. Once you are officially enrolled in the plan, and about the same time as you receive your member ID card, you will receive a separate welcome kit. The kit provides additional information to help you get to know your new plan.

3. Use your ID Card. On your effective date, you can begin using your new ID card to enjoy your benefits and services.

We look forward to helping you live a healthier, more active retirement.

Frequently asked questions.

What to expect next.Please follow your plan sponsor’s instructions regarding how to enroll or make changes to your plan choices.

1. Will I have to change doctors if I select the Trust’s Senior Supplement plan? With this plan you can go to any doctor or hospital that accepts Medicare. As long as your doctor accepts Medicare you will not have to change doctors. There are no networks.

2. Where are the Plan benefits described? Specifics about what you pay and what the Plan pays can be found in the UnitedHealthcare Plan Summary.

3. Do I need to call for prior authorization of a service? No prior authorization or referral is required for any services covered under the plan.

4. Are pre-existing conditions covered? Yes. Medicare-covered conditions are covered by the plan with no limitations for pre-existing conditions or waiting periods.

5. When enrolled in the plan, do I have to continue paying my Medicare Part B monthly premiums? Yes. You must be enrolled in Medicare Part A and Part B to be eligible to enroll in this plan. If you’re not sure you are enrolled, check with your local Social Security office. You must continue paying your Medicare Part B premium to keep your coverage under this group-sponsored plan. If you stop your payments, you may be disenrolled from this plan.

For questions on your medical or prescription drug benefits, call UnitedHealthcare Customer Service toll-free:

1-877-717-9517, TTY 711 8 a.m. to 8 p.m. local time, Monday – Friday

Or visit www.uhcretiree.com/delta

Questions?

SilverSneakers® is a registered mark of Healthways, Inc. Consult a health care professional before beginning any exercise program. Availability of the SilverSneakers program varies by plan/market. Refer to your Evidence of Coverage for more details.

UnitedHealthcare Senior Supplement group retiree plans are underwritten by UnitedHealthcare Insurance Company, a private insurance company not connected with or endorsed by the U.S. Government or the federal Medicare program. UnitedHealthcare is part of the UnitedHealth Group family of companies. UnitedHealthcare Senior Supplement plans are not Medicare Supplement plans. They are employer group retiree plans and may provide coverage that is different from a Medicare Supplement plan. In New York, the plans are called UnitedHealthcare Retiree Benefit Plans and are underwritten by UnitedHealthcare Insurance Company of New York. Senior Supplement plans may not be available in all states.

UHEX13SS3463715_000 SPRJ14256

Documents

Insurance Trust for Delta Retirees 2013 Medical Benefit Plan