about your benefits and how to find a network provider for all of your

Transcription

1 GM Benefits & Services Center gmbenefits.com nternational Access Dial AT&T Direct" Access Code then TTY Service for Hearing or Speech mpaired June Dear UAW General Motors Hourly Enrollee: The General Motors hearing program for UAW employees and their eligible dependents enrolled in the Traditional Care Network (TCN) plan will be provided through AudioNet America administered by SVS Claims Management effective July This means that your hearing aid benefits will no longer be administered by Blue Cross Blue Shield. Below you will find information hearing needs. about your benefits and how to find a network provider for all of your Benefit nformation You and your eligible dependents will automatically be enrolled in the AudioNet America Hearing Aid Program effective July n-network hearing aid covered services received from an AudioNet America Provider will be covered as outlined on the enclosed Hearing Aid Summary of Benefits. All services require preauthorization by SVS Claims Management. n-network: o Standard hearing aid services provided by AudioNet America participating providers (innetwork providers) are covered in full. Upgrades are available at additional cost to the member. View the attached-hearing aid-summary of Benefits for detailed hearing aid benefits and coverage. Out-of-Network: o f you live within 25 miles of an AudioNet America participating provider covered hearing aid services that are obtained from a Non-Network provider are not covered. o f there is not an AudioNet America in-network provider within 25 miles of your home you must contact SVS Claims Management at (866) prior to receiving services so special arrangements can be made. Page 1 of 2 3.GM-H-814X.100

2 Finding a Participating Provider By choosing an AudioNet America in-network provider you are eligible to receive covered benefits with no out-of-pocket costs. We encourage you to choose an in-network provider to avoid unnecessary out-off;.: pocket expenses. To identify an in-network provider you should: Contact SVS Claims Management at (866) or access their website at on "Claims Manager." dentification Card (10 card) You will not receive a separate D card from SVS Claims Management for hearing aid services. However you should contact SVS Claims Management at (866) prior to obtaining hearing aid services mportant - Do not use your present BeBS D card for hearing aid services on or after July f you have any questions please contact the GM Benefits & Services Center at Monday through Friday between 7:30 a.m. and 6:00 p.m. Eastern Time zone to speak with a Customer Service Associate. Sincerely GM Benefits & Services Center Enclosure: Summary of Benefits Page 2 of 2 3.GM-H-814X.100

3 UAW-GM Hourly Active HEARNG AD COVERAGE Summary of Benefits All services require preauthorlzatlcn. Providers seeking authorization or members ~ith questions or who are seeking Network Providers in their area should call SVS at (866) or click www. audionetamerica com l Service Obtained at a Particioatina Provider Frequency Participating pro\~der means a physician or audiologist who participates i the AudioNet America Hearing Aid Proorarn administered by SVS. Audiometric Covered in Full Once every 16 months beginning 1/1/11. Examination Hearing Aid Covered in Full Once every 36 months per ear beginning 1/1/11. Evaluation Test f Conformity Covered in Full Once every 16 months per ear beginning 1/1/11. Evaluation Digital Hearing Mid-level standard digital hearing aids will be covered in Every 36 months beginning 1/1/11. Aids full.!! Mid-High Level standard digital hearing aids will be covered with a $250/ear member co-payment. \ Advanced Level standard digital hearing aids will be ( covered with a $5001ear member co-payment. Flagship Level stan9ard digital hearing aids will be covered with a $650/ear member co-payment.! ( Administered 1 by~_s CONTACT 5VS AT (866)

4 Service rconn Frequency (cont) Obtained at a Participating Provider (cont)! Dispensing Fee Participating Pr~vidermeans a physician or audtoloqist who participates in the AudioNet America Hearing. Aid Program administered by SVS. Covered in Full Replacement Ear Molds (for children up to age seven) Up to 4 replacement ear molds annually are covered in full for children up to age 3. Up to 2 replacement ear molds annually are covered in full for children ages 3-7. Additional molds are charged to enrollee. No more than 4 replacement ear molds annually for children up to age 3. Not more than 2 replacement ear molds annually for children ages 3-7. Any additional molds are not covered by plan. Ear Molds (Enrollees over aoe 7) Accessories Maintenance 1 Fittings 1 FollowUp visits First is covered in full. Additional molds are charged to enrollee. First is included with initial hearing aid. Any additional molds are not covered by plan. ; " "; i'" 21'.ii. Once every 36 months per ear beginning 1/1/11 '. ; " Not Covered Covered in Full within first 6 months i Out of Network Benefits: f an eligible enrollee lives within 25 miles of a Network provider a Network Provider must be utilized in order to receive coverage. f an eligible enrollee lives within 25 miles of a Network provider and receives hearing aid services and materials from a Non-Network provider there is no coverage. f an eligible enrollee lives more than 25 miles from the closest n-network provider and receives hearing aid services and materials from a Non-Network provider they will be reimbursed at the n-network Discounted Provider Fee Schedule level. 2 S CONTACT SVS AT (866)

5 EXCLUSONS: j Covered hearing aid expense does not include and no benefits are payable for: Services and equipment obtai neb from a Non-Provider (someone who is not a physician or an audiologist); Services and equipment obtained from a Non-Network Provider for eligible enrolle s living within 25 miles of a Network Provider; i Audiometric examinations for an~ condition other than loss of hearing acuity; Medical or surgical treatment; Drugs or other medication; Audiometric examinations he~ring aid evaluation tests and hearing aids prov ded under any applicable Workers Compensation law; Audiometric examinations and hearinq aid evaluation tests performed and hearing aids ordered (1) before the enrollee became eligible for coverage; orj(2) after termination of the enrollee's coverage; Hearing aids ordered while cove}ed but delivered more than 60 days after termination Qf coverage; l Charges for audiometric exarnihations hearing aid evaluation tests and hearing ai s for which no charge is made to the enrollee or for which no charge!would be made in the absence of hearing aid covera e; Charges for audiometric examinations hearing aid evaluation tests and hearing aids hich are not necessary according to professionally accepted standar~s of practice and in the case of an initial hearing aid or any hearing aid for a person under age 18 charges for hearing ai/ti evaluation tests and hearing aids or which are nbt recommended or approved by the audiologist or physician;. ~ Charges for audiometric examinations hearing aid evaluation tests and hearing aids t at do not meet professionally accepted standards of practice including qharqes for any such services or supplies that are exp rimental in nature; Charges for audiometric examinations hearing aid evaluation tests and hearing aids received as a result of ear disease defect or injury due to an act of ardeclared or undeclared; Charges for audiometric examintions hearing aid evaluation tests and hearing aids by any governmental agency that are obtained by the enrollee without cost by compliance with laws or regulations e acted by any federal state municipal or other governmental body; / Charges for any audiometric examinations hearing aid evaluation tests and hearing aids to the extent benefits which are reimbursable under any health care program supported in whole or in part by funds of t e federal government or any state or political subdivision thereof; t = 1 3 Administered by CONTACT SV

6 EXCLUSONS (cont): " Replacement of hearing aids that are lost or broken unless at the time of such replacement the covered person is otherwise eligible under the frequency limitations set forth herein; Charges for the completion of any insurance forms; Replacement parts for and repairs of hearing aids except as otherwise provided for; Charges incurred by persons enrolled in alternative plans; ( Eyeglass-type hearing aids to the extent the charge for such hearing aid exceeds the covered hearing aid expense for one hearing aid; Charges for failure to keep a scheduled visit with a provider; Charges for binaural or "spare" hearing aids unless the covered person qualifies for a binaural hearing aid as referred to under the Schedule of Benefits above; Hearing aids that do not meet Food and Drug Administration (FDA) and Federal Trade Comtnission (FTC) requirements; Expenses for and related to the purchase servicing fitting and/or repair of hearing aid devices purchased outside of the AudioNet America Hearing Network benefit program and/or prior to the implementation of the AudioNet America Hearing Network benefit; Special education and associated costs in conjunction with sign language education for a patient or family members; Charges for state sales tax; or Charges for services except where it is described by an AudioNet American Hearing Network reimbursable procedure code. This is a summary of the benefits available; there are certain exclusions and limitations. For more details call SVS at (866) or click 4 Administered by CONTACT SVS AT (866) GM-H-814XX100