There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:
Where provisions of the Plan conflict with applicable state or federal law, present or future, such legislation shall prevail. The Plan Sponsor is responsible for interpreting the provisions of this Plan. You should rely on information here to estimate or determine benefits available. Information you receive from any source will not be valid if it conflicts with the language of this Plan. If necessary to protect the employee from financial loss, the Plan may negotiate an additional allowance for kidney dialysis.
This group health plan believes it is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Act). As permitted by the Act, a grandfathered health plan can preserve coverage that was in effect when the law was enacted. Being a grandfathered plan means that your plan may not include certain consumer protections of the Act that applies to other plans, for example, the requirement for the provision of preventive health services without any cost sharing.
However, grandfathered plans must comply with certain other consumer protections in the Act, for example, the elimination of lifetime limits on benefits. Questions regarding which protections apply and which protections do not apply to a grandfathered plan and what might cause a plan to change from a grandfathered plan status can be directed to the Plan Administrator. Or you can contact the U.S. Department of Health and Human Services at healthreform.gov.
Under federal law, group health plans and health insurance issuers offering group health insurance coverage generally may not restrict benefits for any hospital lengths of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section.
However, the plan or issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier. Also, under federal law, plans and issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay.
In addition, a plan or issuer may not, under federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain pre-certification. For information on pre-certification, contact your plan administrator.