• Eligibility for Health Care Coverage
• Enrollment for You and Your Dependent(s)
• Plan Year
• Termination of Employee and/or Dependent Coverage
• Utilization Review Programs

BGSU has been and continues to be, conmmitted to providing high-quality benefit coverage at reasonable rates for full-time faculaty and staff. The University's Health Care Plan is self-funded. This means your contributions coupled with BGSU's contributions pay for all services used by their employees and dependents. As the cost for the prescription drugs and health care services rises and utilization of services increases, so must the contributions of employees and BGSU.

Currently, BGSU sponsors a Preferred Provider Plan (PPO). By selecting to participate in the PPO Plans, you are automatically enrolled in the Dental and Prescription Drug Plan. You cannot elect to enroll in the Dental and Prescription Drug Plan without selecting to participate in the PPO. The Health Care Program's design reflects commitment from the University to sharing the costs of the benefits with its employees. While BGSU pays the greater share of the cost of the benefits, you also share in the commitment through your contributions, deductibles and copayments. Your complete understanding and informed use of the Health Care Program reflects a commitment to upholding a share of this important benefit.

This section is designed to help you understand some of the important features of the Health Care Program. The following information applies to all of the Medical Plans as well as the Dental Care Benefits and Prescription Drug Plans.

Eligibility for Health Care Coverage

Employees

An employee must be a full time faculty, administrative or classified employee of BGSU to participate in the Health Care Program. Coverage begins on the 1st day of the month after your date of hire if the required application/enrollment forms have been completed and submitted to the Benefits Office.

Dependent Spouse

The Plan recognize a dependent spouse* is defined as to whom you are "legally married". A legally separated or divorced spouse is not considered eligible for dependent coverage. Common law marriages after October 10, 1991 are not recognized in the State of Ohio, and therefore are not eligible for dependent spouse coverage. For a common law relationship established prior to October 10, 1991, appropriate documentation will be required for dependent spouse coverage.

If you and your spouse both work at BGSU, each can elect individual coverage, or one of you can elect to cover the other as a dependent. BGSU does not provide Cordination of Benefits on itself.

Dependent Child

A child eligible for dependent coverage are unmarried children, stepchildren, legally adopted children, children for whom either the employee or the employee's spouse is the legal guardian or custodian, or any children who, by court order must be provided healthcare coverage by the employee or the employee's spouse.

To be considered eligible depnedents, unmarried children may be covered until the end of the calendar year in which they attain age 23 as long as they meet the following: are not employed full time, and they must receive over half their support during the calendar year from the employee unless coverage is begin provided under court order.

Eligibility will continue past the age limit for eligible dependent children that are unmarried and primarily dependent upon the employee for support due to physical handicap or mental retardation which renders them unable to work. This incapacity must have started before the age limit was reached and must be medically certified by a physician. You must notify the BGSU Office of Human Resources, Benefits, of the eligible depnedent's condition to continue coverage within 31 days of his/her reaching the limiting age. An annual physician certification that the dependence and the incapacity continues may be requested.

Enrollment for You and Your Dependents

You may enroll in the Medical, Dental and Prescription Drug Plan without submitting medical informaton for you or your dependent if you enroll within 31 days of becoming eligible for coverage. To enroll yourself or your dependent, you must complete an application/enrollment form. This form is available in the Benefits Office. Coverage under the Plan becomes effective on the first day of the month following your date of hire provided you have enrolled.

An Open Enrollment period will be offered each year. All eligible participants, even if they have previously opted out of coverage, will be permitted to enroll in one of the health care options at that time.

Changes In Coverage

You may make a change in your coverage (i.e., single to family/family to single) without providing evidence of insurability at any time during the Plan Year if you have a change in family status. A change in family status may occur on account of:

• Marriage;
  
• Divorce;
  
• Birth or adoption of a child;
  
• Death of your dependent spouse or child; or
  
• The loss of or a substantial change in your spouse's coverage.

If one of the above events occur, the changes in the Health Care Program are effective on the first day of the month following the date of the change, provided you notify the Benefits Office within 31 days of the event and the required verification of the change is provided. If you make a change in your coverage within this 31 day period, you are not required to submit any medical information for your dependent(s).

Plan Year

The Plan Year for the Health Care Program is the calendar year, January 1-December 31. Deductibles, Coinsurance, and annual Out-of-Pocket Maximums are also determined on a calendar year basis (January 1 - December 31).

Termination of Employee and/or Dependent Coverage

Your coverage under the Health care Program terminates at the end of the month in which any of the following occur:

• Your employment is terminated (unless you are eligible and elect continuation coverage under COBRA);
  
• You cease to be a full-time contract or classified employee of BGSU (unless you are eligible and elect continuation coverage under COBRA);
  
• You fail to make any required contributions for coverage by the final due date;
  
• You or your dependents cease to be considered eligible under the eligibility provisions of the Health Care Program;
  
• The University discontinues providing coverage to all employees; or
  
• You attempt to obtain benefits through deceit, or help someone obtain benefits in a fraudulent manner.
  

The Plan Year is Janaury 1- December 31, you will be covered through the end of August even if you terminate at the end of your contract in May or June. In other words, if you have completed your nine-month academic contract (September -May) you will receive coverage through the end of August. This also applies to those classified employees who are employed only during the nine month academic year and receive 19 pays during this period.

* As defined and governed by Ohio Law

Utilization Review Programs

BGSU's utilization review (UR) program is a valuable asset to you and your covered dependents. Utilization review includes peer review programs in which physicians and nurses analyze the care provided by other physicians and hospital staffs. They review the setting, necessity, and quality of health care for employees participating in the Medical Plan. Medical Mutual of Ohio (MMO) dental consultants will review dental claims. By using the utilization review programs to their fullest advantage, you know whether the prescribed health care is necessary and appropriate.

Your active role in the UR program can save you from unnecessary discomfort, a lengthy hospital stay or recovery, and wasted money on costly medical procedures for which an alternative treatment may be more appropriate. In addition, by using the utilization review program, you help BGSU provide quality health care in a cost-effective manner.

Medical Mutual of Ohio through PReview ^TM administers the utilization review program for BGSU's Medical Plans. MMO's contracted hospitals share in the responsiblity for administering the program. If a contracting hospital fails to follow the UR program, they will not be reimbursed for medical charges. If you are admitted to a non-contracting facility or an out-of-area hospital, you are responsible for precertifying the admission with MMO. Inquiries regarding contracting hospitals may be made by calling MMO's Customer Service Department.

Hospital Admissions

Medical Mutual of Ohio reviews your physician's recommendations to determine whether the admission or surgical procedure (either on an inpatient or outpatient basis) is medically necessary. Alternatives to inpatient treatment, such as outpatient care, are reviewed, keeping in mind the most appropriate care for your individual situation. Medical Mutual's final decisions are provided to the physician and/or hospital within 24 hours of the time they are contacted.

Mandatory Precertification of Hospital Inpatient Admissions

Should you need to be admitted to the hospital as an inpatient, your admission must be precertified. Physicians and hospitals which are contracted with MMO will precertify admissions for you. However, you are responsible for precertifying admissions to all non-contracting facilities. Call the number on the back of your identification card to precertify. The precertification process will guarantee cost-effective scheduling of care and use of proven cost containment measures to ensure that:

• Preadmission testing (PAT) is performed before a patient is admitted to the hospital. PAT allows subscribers to have pre-surgical x-ray and lab services done as an outpatient.
  
• Weekend admissions are avoided. If a participant is admitted on a Friday, Saturday, or Sunday, there must be a valid medical reason for the admission.
  
• The medical need must be documented by the doctor's office before admission.
  
• Surgery is scheduled on the day of admission to the hospital when medically appropriate.
• Additional pre-operative days in the hospital must be documented during precertification.

   

Admission and Continued Stay Review

All inpatient hospital admission will be reviewed. The purpose of the review is to examine the potential for home health care, outpatient treatment of the use of skilled nursing or extended care facilities to carry out the treatment. The review will take place with the provider of care once Medical Mutual of Ohio has been notified of the hospital admission.

Case Management Services

Some long term illnesses or serious injuries require specialized care. In certain medical situation, receiving this specialized care may mean your stay in the hospital could be extended. Case Management Services examines each person's medical situation on an individual basis. Case Management services includes discharge planning and home health care coordination. MMO coordinates specialized care with you and your doctor so that you can recuperate at home or another facility when possible, rather than in the hospital.

Second Surgical Opinion

Unfortunately, people seek more opinions and do more comparison shopping when buying a new car than when they are told they need surgery. For the most part, one physician's opinion concerning surgery is adequate. Sometimes, however there are medical situations for which treatment options differ. Although BGSU does not require second surgical opinions, the Medical Plans will cover patients who wish to seek another opinion.

Emergency Admissions

If you or a covered dependent is admitted to the hospital for an emergency, including obstetrical, you, the dependent patient, the physician or a member of the hospital staff should contact MMO within 48 hours of the admission. MMO works with your doctor and the hospital staff to ensure that the care you receive is being provided in the most appropriate setting. This review, like the Hospital Admissions review, confirms the medical necessity of your admission. MMO evaluates alternative treatment settings, reviews your admittance into the hospital and determines whether specialist should be used. This review in no way means you will be denied emergency service.

Retrospective Review

MMO evaluates the medical records of individuals whose medical treatment or hospital stay was not reviewed under Hospital and Emergency Admission Certification or Precertification, or the Continued Stay Review.

The Preferred Provider Organization (PPO) Plan

If you use a Super Med network physician or hospital, all of the requirements under the utilization review program will be handled for you by the physician or network hospital. It is you responsibility to precertify admissions to non-contracting and out-of-area hospitals. Failure to precertify may result in partial or total rejection of the hospital claim. An appeal can be made to the Medical Mutual of of Ohio Utilization Management Department ( see Section VI ) . After MMO reviews the charges, medically necessary charges will be paid, less any deductible, copayments, or non-network penalty. Any remaining balance may be your responsibility.

Please Note: Drug coverage is through Caremark , not MMO. The prescription drug plan is automatically included in all active employees coverage.