Retiree Insurance Information Booklet Addendum

• Page 6 — Who is Covered
• Page 17 — Covered Medical Expenses
• Page 26 — Outpatient Procedures and Plan Required Second Opinions
• Page 36 — Prescription Drugs - Exclusions
• Page 49 — Medical Treatment of Obesity
• Page 93 — If a Claim or Certification is Denied
• Page 98 — Continued Health Coverage

Addendum to Page 6 – 7 — Who Is Covered

Effective 9/2004

Important Notice:

Dependents

In accordance with Alaska Statutes 39.35.680(12) and 14.25.220(13):

• If your dependent child is under 23 years old, they are required to be registered at and attending on a full-time basis an accredited educational or technical institution recognized by the Department of Education and Early Development.
• If your dependent child is age 19 or older and is not a full-time student, then the dependent is eligible for coverage only if he or she is totally and permanently disabled. Please contact the Division for additional information about eligibility, and for information about how to provide proof of your dependent's disability.

Effective 1/1/2007

Amended to include:

• Same-sex partner as defined and documented by 2 AAC 38.010 - 2 AAC 38.100.
• Eligible child of same-sex partner as defined and documented by 2 AAC 38.010-2 AAC 38.100.

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Addendum to page 17 — Covered Medical Expenses

Effective 3/1/13

Amended by adding a new subsection to read:

Taxes: Subject to applicable Plan provisions, any portion of a claim that is itemized as sales, excise, or other tax, and that relates to an otherwise covered expense, is reimbursable.

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Addendum to Page 26 — Outpatient Procedures and Plan-required Second Opinions

Effective 1/1/2009

All listed procedures requiring pre-certification have been removed except for the following:

• MRI-knee
• MRI-spine

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Addendum to Page 36 — Prescription Drugs – Exclusions

Effective 1/1/2005

Deleted the following:

• Any contraceptive drug prescribed for contraceptive purposes.

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Addendum to Pages 49-50 — Medical Treatment of Obesity

Effective 12/4/2006

Supersedes 1/2009 revision which was missing Surgical Treatment of Obesity criteria

Medical Treatment of Obesity

Medically necessary expenses for medical treatment of obesity will be covered as any other medical condition when the following criteria are met.

• Body Mass Index (BMI) greater than or equal to 30 kg/m2, or
• BMI greater than or equal to 27 kg/m2 with underlying comorbidities, including but not limited to, cardiopulmonary complications, diabetes, hypertension and obstructive sleep apnea.

Noncovered services currently listed on page 50 is revised to include, but would not be limited to:

• Special diet supplements, vitamin injections, hospital confinement for weight reduction programs, exercise club membership fees, exercise equipment, whole body calorimeter studies, biofeedback and hypnosis.

Surgical Treatment of Obesity

Medically necessary expenses for surgical treatment of obesity will be covered as any other medical condition when the following criteria are met.

• Body Mass Index (BMI) greater than or equal to 40kg/m2 or BMI greater than or equal to 35kg/m2 with underlying comorbidities, including but not limited to, cardiopulmonary complications, diabetes, hypertension and obstructive sleep apnea; and
• Completion of bone growth; and
• Drug/alcohol screen with either no drug/alcohol abuse by history or alcohol and drug free period for greater than or equal to one year; and
• Continued obesity despite medically supervised weight loss treatment for at least six months cumulatively, during the two years prior to surgery, or
• Documentation in the medical record of the member’s participation in a multidisciplinary surgical preparatory regimen of at least three months duration, completed prior to the time of surgery, meeting all of the following criteria:
  • Consultation with a dietician or nutritionist; and
  • Reduced calorie diet program supervised by a dietician or nutritionist; and
  • Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to the surgery, supervised by exercise therapist or other qualified professional; and
  • behavior modification program supervised by qualified professional; and
  • Documentation in the medical record of the member’s participation in the multidisciplinary surgical preparatory regimen

Noncovered services currently listed on page 58 are revised to include, but is not limited to:

• Special diet supplements, vitamin injections, hospital confinement for weight reduction programs, exercise club membership fees, exercise equipment, whole body calorimeter studies, biofeedback and hypnosis.

Covered surgical obesity procedures are limited to:

• Lap Band Gastric Banding, Roux-en Y Gastric Bypass and Vertical Banded Gastroplasty when all selection criteria are met.

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Addendum to pages 93-95 — If A Claim Or Certification Is Denied

Effective 7/1/2005

Replaced in whole due to Board/Review Group abolishment effective 6/30/2005

If a claim or precertification is denied, in whole or in part, your Explanation of Benefits (EOB) or letter from the Claims Administrator will explain the reason for the denial. If you feel your claim or precertification should be covered under the terms of this plan, you should contact the Claims Administrator to discuss the reason for the denial. If you still feel the claim or precertification denial should be covered under the terms of the Plan, you can take the following steps to file an appeal.

Claims Administrator Appeals

Level I Appeal

Submit your request in writing, explaining the nature of your appeal, including copies of EOB’s, correspondence, and pertinent medical records. Your appeal must be received by the Claims Administrator within 180 days of the date the EOB or precertification denial letter was issued. You will receive a written decision from the Claims Administrator within 30 days after their receipt of your appeal. If you are not satisfied with the Level I decision, you can submit a Level II appeal review.

Level II Appeal

The Claims Administrator must receive your written request for a Level II appeal within 60 days of the date the Level I decision letter was issued. Your appeal will be reviewed by a panel who did not participate in the Level I review. You will receive a written decision from the Claims Administrator within 60 days after their receipt of all relevant information in your appeal. If you are not satisfied with their final decision, you can request a review by the Plan Administrator.

Plan Administrator Appeals

If you disagree with the final Claims Administrator’s decision, you can send a written request for review to the Plan Administrator. Your appeal must be postmarked or received within 45 days from the date the Claims Administrator’s final decision letter was issued. The Plan Administrator will request a copy of your Claims Administrator appeal file, including any documentation from your provider for their records and review of your appeal. You may submit additional relevant material with your written appeal. The Plan Administrator will issue a decision within 90 days after receiving all the relevant material in your appeal.

Your appeal may be sent to an Independent Review Organization (IRO). IRO is an organization of medical experts qualified to review your appeal. If your appeal is forwarded to the IRO, the Plan Administrator will issue a decision in writing within 30 days after receiving the IRO’s recommendation. If you are not satisfied with the decision, you may appeal to the Office of Administrative Hearings (OAH).

URGENT Appeals

If your doctor or provider advises the Claims Administrator or Plan Administrator that a delay in your appeal process could harm your health, an emergency review and decision will be made within 72 hours after receipt of your appeal.

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Addendum to page 98-99 — Continued Health Coverage

Effective 5/1/2009

Amended as follows:

Minimum Length of Coverage is changed to Length of Coverage and reads:

Ineligibility for Retirement Benefits

If you lose coverage because you are no longer eligible for a retirement benefit, you may continue coverage for yourself and your eligible dependents for up to 18 months.

Dependents

If your dependents lose coverage due to your death, divorce, or because they do not meet the eligibility requirements, they may continue coverage for up to 36 months. If this change occurs while covered under the continuation plan because you had already lost coverage, the amount of time they have been covered under the continuation plan is subtracted from the 36-month time period.

Disabled Retirees and Dependents

If you or your dependent are disabled when your continuation coverage begins or within 60 days of that date, your length of coverage may be extended an additional 11 months. To elect this additional coverage, you must notify the Division of Retirement and Benefits of your status before the end of your first 18-month coverage period and within 60 days of your Social Security disability determination. The premium may increase for the additional 11 months of coverage. Coverage may be terminated if Social Security determines you are no longer disabled. In this case, you must notify the Division of Retirement and Benefits within 30 days of the final Social Security determination.

Maximum Length of Coverage is removed.

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Reference: Retiree_Insurance_Addendum2011.pdf