Transcription
Martin Marietta Materials, Inc.Personal Choice Benefits Program Medical Plan Summary Plan DescriptionJanuary 2011
Table of ContentsPageIntroduction . 1Purpose . 1Your Medical Plan Coverage At A Glance . 2How Your Medical Plan Coverage Works . 4Eligibility . 4Enrollment . 5Status Changes . 10The BCBS PPO . 16How the PPO Works. 16Reasonable and Customary Charges . 16The Co-payment, Deductible and Co-insurance . 17Out-of-Pocket Limit . 18Pre-admission Certification (PAC) . 19Penalties for Noncompliance . 19Second Opinion for Surgery . 20In-Network Benefits . 20Out of the Network Benefits . 24Emergency Care . 28What Is Not Covered . 28General Limitations . 29Benefit Limitations for BCBS PPO . 30Cigna EAP/Magellan Health Services (Mental Health Substance Abuse) . 34Cigna Employee Assistance Program (EAP). 34Magellan Mental Health and Substance Abuse. 34Covered Services . 37Non-Covered Services . 38Mixed Services Protocol . 38Inpatient Care . 39Emergency . 40Mixed Services Protocol – Examples . 41
Caremark Prescription Drugs . 44Covered Services . 45Non-Covered Services . 47Notice of Credible Coverage . 48Waived Coverage Option . 51Coordination of Benefits (COB) . 51How COB Works. 52COB with Medicare . 52Payments from a Third Party . 53How to File Your Medical Claims . 54BCBS PPO . 54Caremark Prescription Drugs . 55Minimum Standards for Claims Procedures . 56If Your Claim Is Denied . 57How Long Coverage Lasts . 60If you are Disabled . 60Special Continuation for Covered Eligible Dependentsof a Deceased Employee . 61Continuation Coverage Under The Consolidated OmnibusBudget Reconciliation Act (COBRA). 61Continuation of Coverage for Employees in theUniformed Services (USERRA) . 62If You Go on Family or Medical Leave . 63If You Retire . 64HIPAA Certificate of Creditable Coverage . 64Definitions. 65Other Reference Information . 71Statement of ERISA Rights . 73
IntroductionThis booklet is the "Summary Plan Description" for the Martin Marietta Materials,Inc., Medical Plan (the "Plan" or the "Medical Plan"). This booklet summarizes themedical benefits provided by the Personal Choice Benefits Program as in effect forthe calendar year beginning January 1, 2011. The Personal Choice Benefits Programis the flexible benefits program for eligible full-time salaried and hourly employeesof Martin Marietta Materials, Inc. (the "Company"). This SPD serves as the officialPlan Document as required under the Employee Retirement Income Security Act(ERISA) of 1974. If there is any conflict between other plan description materialsand this document, terms outlined in this SPD will govern. This booklet does notgive you any rights to benefits that are not expressly provided under the terms ofthis document. You can receive a copy of this Plan Document from the CorporateHuman Resources Department.Nothing in this booklet creates an employment contract between Martin MariettaMaterials, Inc. and any employee, or prevents the Company from terminating orchanging the terms of any employee's employment.Martin Marietta Materials, Inc. reserves the right to amend or terminate the Plan atany time and in any manner, at its sole discretion. Amendments to the Plan maybe made by the Vice President of Human Resources of the Company or through awritten document identified as an amendment to the Plan. When such changesoccur before the material in this booklet can be revised, you will be notified inwriting. Please keep such "Summary of Material Modifications" communicationswith this Summary Plan Description until such time as new booklets are distributed.Benefit provisions described herein may not be applicable for collectively bargainedgroups. Union employees should refer to their specific labor agreements for adescription of their benefits.PurposeIf you elect to participate, the Medical Plan provides for the payment orreimbursement of certain medical expenses incurred by you or your covered eligibledependents.In addition to describing the benefits available under the Plan, this summaryexplains how the Medical Plan works, when and how you and your eligibledependents become covered, when coverage is effective, how to file your claimsand when coverage ends.This Plan is subject to the provisions of the Employee Retirement Income SecurityAct of 1974, as amended ("ERISA").1
Your Medical Plan Coverage At A GlanceEligibility:You are eligible to participate in the Plan on the day you start workas a regular full-time salaried or hourly employee in a ParticipatingBusiness Unit of Martin Marietta Materials, Inc. You may also electcoverage for your eligible dependents.Categories ofCoverage:You may select from four categories of coverage: Employee Employee plus one dependent Employee plus two dependents Employee plus three dependents Employee plus four or more dependentsEnrollment:You may enroll in the Medical Plan within 30 days of your date ofhire, during any applicable ―special enrollment period‖, or during theannual open enrollment period.Benefits:The Medical Plan provides medical benefits through the Blue CrossBlue Shield (BCBS) Personal Choice Preferred Provider Organization(PPO). The BCBS PPO includes the Traditional PPO and the RuralPPO, depending on location. The Plan pays part of your coveredmedical expenses, in some cases after you pay applicabledeductibles. For BCBS PPO participants, the Plan includes mentalhealth and substance abuse services through Magellan BehavioralHealth and prescription drug services through Caremark. EmployeeAssistance Program (EAP) services are provided through CignaBehavioral Health.Cost:Premiums for this coverage will be automatically deducted from yourpaycheck. The Plan is self-insured, so after your applicable co-pays,deductibles and co-insurance rates for services have been paid, theCompany pays the remainder of the costs of the Plan. Yourpremiums are set forth in enrollment materials provided during theapplicable open enrollment period and may be changed from time totime at the Company's discretion.Case & DiseaseMgmt Surcharge:Non-compliance in a case management or disease managementprogram offered by BCBSNC to a covered employee or coveredspouse will result in a 50 per month surcharge per incidence(maximum of 100 per family – surcharge not to exceed maximumamount allowed under Federal regulations to include the smokersurcharge). The surcharges will be applied monthly and willcontinue until you and/or your covered spouse are compliant withthe disease and/or case management program requirements or areno longer eligible for the program. These requirements will bedetermined by Blue Cross and Blue Shield of North Carolina. All2
SmokerSurcharge:program information is confidential and all program terms complywith federal law.The smoker surcharge is an additional pre-tax contribution you makebecause you and/or your covered spouse use tobacco products on afrequent or daily basis. The surcharge is equal to 70.00 per month or 840.00 peryear and applies in addition to the standard medicalcontribution for your category of coverageTobacco products include cigarettes, clove cigarettes, cigars,pipe tobacco and smokeless tobacco.If you waive medical coverage, the smoker surcharge doesnot applyOnly one smoker surcharge applies, even if both you and yourcovered spouse use tobaccoFrequent or daily use includes using any tobacco products atleast once a day or on a frequent regular basis in the past 12months (as measured from your date of enrollment).Surcharge can only be removed during Open Enrollment with12 months no tobacco use prior to current Open Enrollment.Ex: for the 2011 benefit year, you will need to be tobacco freefor 12 months prior or October 2010 but your payrolldeductions will continue through December 31st of the currentplan yearAnyone found falsifying his/her smoking status will be subject todisciplinary action up to and including termination of benefits inaccordance with the Martin Marietta Code of Ethics and Standards ofConduct Policy.If it is unreasonably difficult due to a medical condition for you toachieve the standards to avoid the surcharges under theseprograms, or if it is medically inadvisable to attempt to achievethese standards, call us at 1-877-651-5353 and we will work withyou to develop options for discontinuing the surcharges.Working SpouseSurcharge:If you have a working spouse, who has medical coverage availableto him/her from another employer and/or who is Medicare eligibleand he/she chooses to elect the Martin Marietta Materials medicalcoverage, you will pay a pre-tax surcharge equal to 110.00 permonth or 1320.00 per year, in addition to the standard medicalcontribution for your category of coverage.ClaimsAdministrators:Medical: Blue Cross Blue Shield (BCBS)Mental Health and Substance Abuse: Magellan Health ServicesPrescription Drugs: Caremark3
Employee Assistance Program (EAP): Cigna Behavioral Health (CBH)If you have Medicare or will become eligible for Medicare in the next 12 months,Federal law gives you more choices about your prescription drug coverage.Please see page 53 for more details.How Your Medical Plan Coverage WorksEligibilityYou can elect to have Medical Plan coverage for yourself, you and your spouseand/or eligible dependents or you can elect the Waived Coverage Option. You mayparticipate in the Plan if: You are an active, full-time salaried or hourly employee who works for aParticipating Business Unit; You properly enroll yourself (and, where applicable, your spouse and eligibledependents); and You pay any required premium.Medical coverage is effective on the day you commence employment at thatbusiness unit, for you, your spouse (if enrolled) and any eligible dependents (ifenrolled). Full time employment is defined as follows: During ―regular business conditions‖, you must work (or be regularly scheduledto work) at least 40 hours per week. Your Participating Business Unit will defineregular business conditions. If your hours (actually worked or regularlyscheduled to work) fall below the 40-hour weekly minimum, you will loseeligibility for coverage under the Plan. You may then become eligible to electcontinuation of coverage under COBRA During ―special business conditions‖, you must work (or be regularly scheduledto work) at least 32 hours per week. Special business conditions will be definedby your Participating Business Unit and may be adopted from time to timewithout advance notice. Coverage levels and required contributions underspecial business conditions will generally remain the same as under regularbusiness conditions, except that coverage and contributions for life insuranceand LTD benefits (salaried employees only) based on your pay will be adjustedto reflect your pay under a 32-hour work week. If your hours (actually workedor regularly scheduled to work) fall below the 32-hour weekly minimum, you willlose eligibility for coverage under the Plan. You may then become eligible toelect continuation of coverage under COBRA4
Eligible dependents include your spouse and any unmarried or married dependentchildren up to 26 years of age. No spouse or dependents of the married dependentmay be covered. Coverage terminates on the 26th birthday for any eligibledependent.The term "children" includes your natural and adopted children, stepchildren orother children who live with you in a parent-child relationship.You can extend coverage to any child who is dependent on you because of aphysical or mental disability beyond age 26 if unmarried. To extend coverage, youmust submit proof of your child's incapacity to the plan administrator within 30days after the date coverage would normally end. You may also be asked toprovide proof of the child's continuing incapacity.If you and your spouse work for the Company, each of you can elect the coverageoption and category you want. However, you cannot be covered as a dependent ifyou are covered as an employee. Only one parent may cover a dependent child.EnrollmentNew EmployeesYou are automatically enrolled into coverage under the Blue Cross Blue Shield PPOmedical plan at no charge on your first day of work. You will then be eligible toenroll your spouse, if applicable any eligible dependents and select the Medical Planoption you want beginning the day you start work and during the first 30 days afteryou start work. Provided you properly enroll yourself and any family members,medical coverage for you, your spouse (if applicable) and any eligible dependentswill be effective on your first day of work. Your premium contributions to the Planwill commence with the first payroll, after the 1st of the month following 30 days ofemployment. Coverage and any required contributions for coverage will stay ineffect until December 31 of the calendar year in which you start work, unless youhave a qualified event status change that allows you to change your Medical Plancoverage category.Your elections will apply to you, a spouse and any eligible dependents you enroll inyour coverage.Annual Open EnrollmentAnnual open enrollment takes place each year. Elections made during annual openenrollment will be in effect for the next calendar year. This is the Medical Plancoverage period. For example:5
Annual OpenEnrollmentMedical Coverage PeriodFall 2010January 1, 2011- December 31, 2011Fall 2011January 1, 2012- December 31, 2012The coverage categories for the Medical Plan are: employee only, employee plusone dependent, employee plus two dependents, employee plus three or employeeplus four or more dependents. This coverage is separate from vision and dentalcoverage, so you can choose a different coverage category. You may also choosethe "waived coverage" option.You will not be able to change your coverage until the next annual open enrollment,unless you have a qualified event status change that allows you to change yourMedical coverage category.Special EnrollmentIf you waive coverage solely because you are insured through another source, youand/or your spouse and eligible dependents may qualify for ―special enrollment.‖Should you lose coverage under the other health plan, you may enroll in this Planduring the calendar year. You must apply for coverage within 30 days of your dateof loss of other coverage and you must contact Benefits Connection at 1-877-6515353 or go to their web-site at: https://mmm.benefitcenter.com, to make your planchanges.To qualify as a special enrollee you must be covered either: Under a COBRA continuation provision and have used up the coverage underthat provision, or Not under a COBRA provision and have lost coverage because eligibility was lostor employer contributions were terminatedIf you believe you qualify for special enrollment based on other conditions not listedabove, please contact the Corporate Human Resources Department for furtherinformation.Children’s Health Insurance Program (CHIP):This law amends ERISA, the Internal Revenue Code and the Public Health ServiceAct allowing an employee who is eligible, but not enrolled for coverage under themedical plan, to enroll outside of open enrollment if either:oThe employee or dependent covered under Medicaid or CHIP has coverageterminated as a result of loss of eligibility, and the employee requestscoverage under the group medical plan within 60 days after suchtermination; or6
oThe employee or dependent becomes eligible for Medicaid or CHIP premiumassistance if the employee requests coverage within 60 days after theeligibility determination dateMedicaid and the Children’s Health Insurance Program (CHIP)Offer Free Or Low-Cost Health Coverage To Children And FamiliesIf you are eligible for health coverage from your employer, but are unable to afford the premiums, someStates have premium assistance programs that can help pay for coverage. These States use funds fromtheir Medicaid or CHIP programs to help people who are eligible for employer-sponsored healthcoverage, but need assistance in paying their health premiums.If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below,you can contact your State Medicaid or CHIP office to find out if premium assistance is available.If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any ofyour dependents might be eligible for either of these programs, you can contact your State Medicaid orCHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If youqualify, you can ask the State if it has a program that might help you pay the premiums for an employersponsored plan.Once it is determined that you or your dependents are eligible for premium assistance under Medicaid orCHIP, your employer’s health plan is required to permit you and your dependents to enroll in the plan –as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This iscalled a “special enrollment” opportunity, and you must request coverage within 60 days of beingdetermined eligible for premium assistance.If you live in one of the following States, you may be eligible for assistance paying your employerhealth plan premiums. The following list of States is current as of March 3, 2010. You shouldcontact your State for further information on eligibility –ALABAMA – MedicaidCALIFORNIA – MedicaidWebsite: http://www.medicaid.alabama.govWebsite: http://www.dhcs.ca.gov/services/Pages/TPLRD CAU cont.aspxPhone: 1-800-362-1504Phone: 1-866-298-8443ALASKA – MedicaidCOLORADO – Medicaid and CHIPWebsite: d/Phone (Outside of Anchorage): 1-888-318-8890Medicaid Website: http://www.colorado.gov/Medicaid Phone: 1-800-866-3513Phone (Anchorage): 907-269-6529CHIP Website: http:// www.CHPplus.orgARIZONA – CHIP7
Website: P Phone: 303-866-3243Phone: 602-417-5422ARKANSAS – CHIPFLORIDA – MedicaidWebsite: http://www.arkidsfirst.com/Website: one: 1-888-474-8275Phone: 1-866-762-2237GEORGIA – MedicaidMONTANA – MedicaidWebsite: http://dch.georgia.gov/Website: entindex.shtmlClick on Programs, then MedicaidTelephone: 1-800-694-3084Phone: 1-800-869-1150IDAHO – Medicaid and CHIPNEBRASKA – MedicaidMedicaid Website: www.accesstohealthinsurance.idaho.govWebsite: http://www.dhhs.ne.gov/med/medindex.htmMedicaid Phone: 208-334-5747Phone: 1-877-255-3092CHIP Website: www.medicaid.idaho.govCHIP Phone: 1-800-926-2588INDIANA – MedicaidNEVADA – Medicaid and CHIPWebsite: http://www.in.gov/fssa/2408.htmMedicaid Website: http://dwss.nv.gov/Phone: 1-877-438-4479Medicaid Phone: 1-800-992-0900IOWA – MedicaidCHIP Website: http://www.nevadacheckup.nv.org/CHIP Phone: 1-877-543-7669Website: www.dhs.state.ia.us/hipp/Phone: 1-888-346-9562KANSAS – MedicaidNEW HAMPSHIRE – MedicaidWebsite: https://www.khpa.ks.govWebsite: efault.htmPhone: 800-766-9012Phone: 1-800-852-3345 x 5254KENTUCKY – MedicaidNEW JERSEY – Medicaid and CHIPWebsite: http://chfs.ky.gov/dms/default.htmMedicaid Website: /medicaid/Phone: 1-800-635-2570Medicaid Phone: 1-800-356-1561LOUISIANA – MedicaidCHIP Website: http://www.njfamilycare.org/index.htmlWebsite: www.dhh.louisiana.gov/offices/?ID 92CHIP Phone: 1-800-701-0710Phone: 1-888-342-6207MAINE – MedicaidNEW MEXICO – Medicaid and CHIPWebsite: http://www.maine.gov/dhhs/oms/Medicaid Website: http://www.hsd.state.nm.us/mad/index.htmlPhone: 1-800-321-5557Medicaid Phone: 1-888-997-2583MASSACHUSETTS – Medicaid and CHIPCHIP lick on Insure New MexicoCHIP Phone: 1-888-997-2583Medicaid & CHIP Website:http://www.mass.gov/MassHealthMedicaid & CHIP Phone: 1-800-462-1120MINNESOTA – MedicaidNEW YORK – Medicaid8
Website: http://www.dhs.state.mn.us/Website: http://www.nyhealth.gov/health care/medicaid/Click on Health Care, then Medical AssistancePhone: 1-800-541-2831Phone: 800-657-3739MISSOURI – MedicaidNORTH CAROLINA – MedicaidWebsite: http://www.dss.mo.gov/mhd/index.htmWebsite: http://www.nc.govPhone: 573-751-6944Phone: 919-855-4100NORTH DAKOTA – MedicaidUTAH – icalserv/medicaid/Website: http://health.utah.gov/medicaid/Phone: 1-866-435-7414Phone: 1-800-755-2604OKLAHOMA – MedicaidVERMONT– MedicaidWebsite: http://www.insureoklahoma.orgWebsite: http://ovha.vermont.gov/Phone: 1-888-365-3742Telephone: 1-800-250-8427OREGON – Medicaid and CHIPVIRGINIA – Medicaid and CHIPMedicaid .shtmlMedicaid Website: http://www.dmas.virginia.gov/rcpHIPP.htmMedicaid Phone: 1-800-359-9517Medicaid Phone: 1-800-432-5924CHIP Website:http://www.oregon.gov/DHS/healthplan/app benefits/ohp4u.shtmlCHIP Website: http://www.famis.org/CHIP Phone: 1-866-873-2647CHIP Phone: 1-800-359-9517PENNSYLVANIA – MedicaidWASHINGTON – Apply.shtmPhone: 1-877-543-7669Phone: 1-800-644-7730RHODE ISLAND – MedicaidWEST VIRGINIA – MedicaidWebsite: www.dhs.ri.govWebsite: http://www.wvrecovery.com/hipp.htmPhone: 401-462-5300Phone: 304-342-1604SOUTH CAROLINA – MedicaidWISCONSIN – MedicaidWebsite: http://www.scdhhs.govWebsite: 095.htmPhone: 1-888-549-0820Phone: 1-800-362-3002TEXAS – MedicaidWYOMING – MedicaidWebsite: alth.wyo.gov/healthcarefin/index.htmlPhone: 1-800-440-04939
Telephone: 307-777-7531To see if any more States have added a premium assistance program since March 3, 2010, or for moreinformation on special enrollment rights, you can contact either:U.S. Department of LaborEmployee Benefits Security Administrationwww.dol.gov/ebsa1-866-444-EBSA (3272)U.S. Department of Health and Human ServicesCenters for Medicare & Medicaid Serviceswww.cms.hhs.gov1-877-267-2323, Ext. 61565Status ChangesYou may make certain changes to your Medical Plan coverage during the coverageperiod if you experience a qualified status change, including: You or an eligible dependent experience loss of other medical coverage(including through exhaustion of COBRA continuation coverage), and the losswas not due to a failure to pay premiums or to your misconduct Your legal marital status changes for reasons of marriage or divorce (requires acopy of the divorce decree). If the decree mandates the employee must pay forcontinuous coverage for the ex-spouse, coverage must be obtained from asource out-side of Martin Marietta Materials benefit plan, legal separation(requires a copy of the separation agreement – same rules apply as the divorcedecree pertaining to payment of continuous coverage), annulment, or death of aspouse A Common Law spouse may be added with a completed Affidavit for CommonLaw Marriage only if the employee resides in a State that acknowledgesCommon Law Marriage (see the affidavit form for a listing of those states orcontact Benefits Connection at 1-877-651-5353) You gain dependent(s) due to marriage, birth, adoption or placement foradoption of a child You lose dependent(s) by divorce, legal separation, annulment, death of adependent, or loss of dependent child eligibility You or an eligible dependent begins or terminates employment, experiences achange in his or her hours of employment or changes residences, which resultsin a loss or gain of medical coverageMedical coverage is extended under the following terms if you are absent from workunder an approved Short-Term Disability (STD) and/or Sickness and Accident (S&A)leave:10
Your medical coverage while on Short-Term Disability (STD) and/or Sicknessand Accident (S&A) continues on the same basis (coverage election) as yourcoverage during active employment You will be able to change your coverage election only if you experience aqualified status change or are eligible for a special enrollment right as describedin this document, Page 10 Your contributions will continue to be withheld from your pay on a pre-tax basisunder the Company’s salary continuation Short-Term Disability (STD) and/orSickness & Accident (S&A) program Contributions will be based on the premiums applicable at that time for activeemployees enrolled in the same level of coverage If you are disabled during annual enrollment, you are allowed to change yourcoverage election during the enrollment period For Salaried employees, coverage can continue for up to six months (basedupon length of service) from your date of Short Term Disability (STD) as long asyou remain disabled under the plan For Hourly employees, coverage can continue for up to the maximum durationof your Sickness and Accident (S&A) coverage allowable based on your years ofservice as long as you remain disabled under the plan Your employment with Martin Marietta Materials continues during STD and/orS&A absenceFor Salaried employees, if you qualify for income payments under the Company’sLong Term Disability (LTD) insurance plan, medical coverage will be continuedunder the following terms: Your medical coverage while on LTD continues on the same basis (coverageelection) as your coverage while on STD Your contributions will be frozen at the level that applied at the end of yourperiod of STD absence and will stay at this level as long as you remain disabledand do not change your coverage election Your medical contributions will be billed to you through the COBRA administrator(currently Ceridian Benefits Billing Services) You may change your coverage level in certain circumstances as described inthe Special Enrollment section of this document. If under Special Enrollment11
you increase your coverage election (e.g., by adding coverage for an eligiblespouse), then the contribution you pay will be set at the level applicable foractive employees with the same coverage level at the time of your electionchange. This new contribution level will then be frozen for the duration of yourLTD absence, or until another medical election change If
medical benefits provided by the Personal Choice Benefits Program as in effect for the calendar year beginning January 1, 2011. The Personal Choice Benefits Program is the flexible benefits program for eligible full-time salaried and hourly employees of Martin Marietta Materials, Inc
