Health Care Benefits for UAW and IBEW

In Detail...

INTRODUCTION

Vought Aircraft offers medical plan options designed to help pay medical expenses for you and your eligible dependents. Each option has maximums, eligible and ineligible expenses, and payment limits. To get the most out of your chosen medical plan option, it is important to know in advance your share of the cost.

The following pages describe features of the Premium PPO in detail.

back to top

IN- OR OUT-OF-NETWORK — THE CHOICE IS YOURS

Under the Premium PPO there are two levels of benefits: in-network and out-of-network. If you live within the network area, each time you or an enrolled family member needs medical care, you can decide whether to use a health care provider who is part of Blue Cross Blue Shield's network and receive in-network benefits. Or, you can use a provider who is not part of the network and receive out-of-network benefits.

back to top

IN-NETWORK SAVES YOU MONEY!

When you receive in-network care, the Premium pays a higher level of benefits. You pay a lower deductible and smaller copayments; for in-network care.

back to top

ACCESS TO IN-NETWORK BENEFITS

Premium PPO

The network under the Premium PPO plan is "portable." You are not limited to Blue Cross Blue Shield network providers in your state, and you can receive care from any Blue Cross Blue Shield network provider in any state in the United States.

back to top

OUT-OF-NETWORK BENEFITS

Premium PPO

You receive out-of-network benefits when you visit an out-of-network provider even if there are no network providers in your area. If you live outside the U.S., you may be eligible for out-of-area benefits.

back to top

BENEFIT PLAN YEAR DEDUCTIBLE

Expenses for Which There Is No Deductible

• Preventive care expenses, such as an annual physical, for adults and children age 6 and older

Expenses That Do Not Count Toward the Deductible

These expenses do not count toward meeting your benefit plan year deductible under the Premium PPO:

• Copayments for in- and out-of network benefits
  
• Expenses that exceed the URC charge, as determined by the claims administrator
  
• Any precertification penalties you incur
  
• Penalties for out-of-network hospital visits
  
• Charges for prescription drugs through Caremark
  
• Charges that exceed the benefit plan year maximum
  
• Charges for mental health and substance abuse treatment
  
• Vision and hearing expenses
  
• Ineligible expenses, such as cosmetic surgery or experimental procedures
  

back to top

WHAT IS A COPAYMENT?

When an in-network provider charges you for an office visit, you make a copayment directly to the provider. (If you have a Flexible Spending Account and your provider accepts Master Card, you may be able to use your debit card for your copay and avoid filing a claim for reimbursement of your costs.)

The amount of the copayment varies. You will pay a $20 copayment on each visit to the:

• Family Practitioner
  
• General Practitioner
  
• Internal Medicine Specialist
  
• Pediatrician
  
• Obstetrician/Gynecologist (OB/GYN)
  
• Chiropractor

You pay a $40 copayment when you see a specialist. You pay a copayment every time you visit a provider, regardless of the number of times in a benefit plan year you may visit. Copayments do not apply to your deductible or out-of-pocket maximum.

WHAT IS COINSURANCE?

After you meet the benefit plan year deductible, the Vought Aircraft medical plan PPO pays a percentage of your eligible expenses; you pay the remaining amount. The amount YOU pay is called "coinsurance." Coinsurance amounts apply to your out-of-pocket maximum.

Premium PPO

After you meet the benefit plan year deductible, the Vought Aircraft Industries, Inc. the Premium PPO plan pays a percentage of your eligible expenses; you pay the remaining amount. The amount YOU pay is called "coinsurance." Coinsurance amounts apply to your out-of-pocket maximum.

back to top

WHAT IS AN OUT-OF-POCKET MAXIMUM?

Under the Preminm PPO plan, there are separate out-of-pocket maximums for in- and out-of-network care.

In-network expenses count only toward the in-network maximum. Out-of-network expenses count only toward the out-of-network maximum. That means, if you receive both in- and out-of-network care under the Preminm PPO, you may need to meet two out-of-pocket maximums before the option pays 100% of your eligible expenses.

back to top

WHAT IS THE LIFETIME MAXIMUM?

The lifetime maximum is the total amount the medical plan pays for each enrolled individual. If the medical plan option you choose has a lifetime maximum, every dollar the medical plan pays toward your medical expenses reduces your lifetime maximum by the same amount.

The lifetime maximum applies to benefit payments combined for all of the Vought Aircraft health care programs for active employees in which you or your dependents participate or participated in the past. This includes the medical plan options, the prescription drug program, and the mental health and substance abuse benefits. However, it does not include vision or hearing benefits.

The lifetime maximum benefit under the PPO plans is $8,000,000 per person.

Annual Restoration

At the start of each benefit plan year, the Premium PPO restores all or a portion of your lifetime maximum. The amount restored equals the amount paid by the carrier during the previous benefit plan year - up to a maximum restoration of $25,000.

Other Lifetime Maximums

Other lifetime maximum benefits that apply to the PPO plans include $20,000 for infertility services and $500 for wigs. A lifetime maximum of two chemical dependency rehabilitation admissions, combined for in- and out-of-network treatment, also applies.

back to top

USUAL, REASONABLE AND CUSTOMARY

URC applies only to out-of-network treatment or services under the Premium PPO. Why? Because the negotiated rates charged by network providers are always within the URC limits.

back to top

Premium PPO

The Premium PPO pays 90% of eligible expenses incurred at in-network urgent care facilities.

MEDICALLY NECESSARY

The medical plan options pay benefits for eligible expenses that are considered medically necessary by the claims administrator. A treatment, service or supply is considered medically necessary by the claims administrator if it meets the following criteria:

• Ordered and approved by a licensed physician
  
• Reasonably required for the diagnosis or treatment of a medical symptom or condition
  
• A treatment that is economical, safe, and provided in a manner and setting consistent with generally accepted United States medical standards
  
• Not primarily for the convenience of the patient or the health care provider
  
• The most appropriate level of treatment, service or supply that can be safely provided (With respect to hospitalization, this means that acute care as an inpatient is necessary due to the type of services the patient is receiving or the severity of the patient's condition. This also means that safe and adequate care cannot be received as an outpatient or in a less intense medical setting.)
  
• Not educational, vocational, experimental or investigational in nature
  
• Not specifically excluded by the plan.

For mental health and substance abuse treatment to be considered medically necessary by the claims administrator, the treatment must be:

• Adequate and essential for the condition
  
• Expected to improve the patient's condition or level of functioning.

Just because your physician or other health care provider prescribes, orders, recommends or approves a service or supply, it is not automatically considered medically necessary.

This rule applies even if the service or supply is not listed in this guide as an ineligible expense. This is one of the important reasons for precertification.

Services provided to you as a hospital inpatient are medically necessary if they cannot be safely provided to you as an outpatient. And, keep in mind that when you are hospitalized, your provider and the claims administrator determine for how long your hospital stay is medically necessary.

Adult physicals, newborn baby care and childhood immunizations that you receive from a network provider are considered medically necessary. Maternity hospital stays for mothers and newborn children are considered medically necessary for at least 48 hours following a normal vaginal delivery or 96 hours following a caesarean birth.

Out-of-network services and supplies provided to a newborn child are considered medically necessary if they:

• Meet all of the requirements listed here
  
• Are provided to treat a diagnosed sickness or injury (including a congenital defect or birth abnormality).

back to top

EMERGENCY CARE

If you need emergency care:

• Go immediately to the nearest hospital emergency room.
  
• When you arrive, show your Blue Cross Blue Shield identification card.
  
• If you need emergency treatment, call Blue Cross Blue Shield at 1-800-571-1041 within 72 hours of receiving emergency treatment and you will receive in-network benefits. If you are unable to call, arrange to have someone - a friend, relative, physician or member of the hospital staff - call for you. If you are admitted to the hospital and fail to notify Blue Cross Blue Shield, you will pay a $500 penalty.

back to top

AMBULANCE SERVICE

All the medical plan options cover ambulance service for emergency transportation to the nearest hospital; for instance, if you have a heart attack. Afterwards, if necessary, you may be transferred to another hospital that has a cardiac care unit. As long as the transfer is necessary and not for patient convenience, cost of the second ambulance would be processed at the appropriate benefit level provided by your plan.

back to top

URGENT CARE

Urgent care facilities provide urgently needed, routine treatment at times when your regular physician is unavailable, such as evenings and weekends.
Benefits for urgent care differ by medical plan option, as follows.

Premium PPO

The Premium PPO pays 90% of eligible expenses incurred at in-network urgent care facilities.

back to top

PRECERTIFICATION IS REQUIRED

If you are enrolled in the PPO Premium plan, you must obtain pre-certification from Blue Cross Blue Shield. Mandatory pre-certification helps manage medical costs by confirming the need for the following situations and others:

• A non-emergency hospital stay
  
• Extension of a precertified hospital stay (When you initially precertify a hospital stay, Blue Cross Blue Shield authorizes a specific number of days in the hospital. If you need to extend your stay in the hospital, you must call Blue Cross Blue Shield to precertify the extension. This includes extended maternity stays beyond those described here.)
  
• Skilled nursing facility care
  
• Private duty nursing
  
• Home health care
  
• Hospice care
  
• Inpatient surgery

back to top