PURMS

[ Log In ]
August 1, 2001

 

 

 

 

logo

PUBLIC UTILITY DISTRICT 3 OF MASON COUNTY

EMPLOYEE HEALTHCARE PLAN

2017


 

 

 

 

January 1, 2017                                                                                                

Dear Fellow Employees of Mason County PUD No. 3,

We are pleased to provide you with a comprehensive overview of the Mason County PUD 3 Healthcare Plan (Plan) which includes medical, vision and prescription drug coverage. Because we belong to a self-insured provider, we enjoy a quality level of benefits while keeping the health care costs low. You can play a part in keeping the rates low for all Plan participants by utilizing the preventative measures provided in the Plan. 

This booklet describes the benefits that are available to you as a participant in the Plan. If you have specific questions regarding your Plan’s benefits or the procedures necessary to receive these benefits, please contact PUD 3’s Benefits Coordinator in the Human Resources department or you can call our Claim Administrator (Pacific Underwriters) at the following toll free number 1-800-562-5226.

We wish you the best of health for 2017 and into the future.

Warm Regards,

Annette Sign

 

 

 

P.O. Box 2148 · Shelton, WA 98584 (Bus) 360/426-8255 · (Fax) 360/426-8547


PLAN SPECIFICATIONS

PLAN ADMINISTRATOR                                         Mason County PUD No. 3

                                                                                    307 W. Cota Street

                                                                                    P. O. Box 2148

                                                                                    Shelton, Washington 98584

TELEPHONE NUMBER OF PLAN

ADMINISTRATOR                                                    (360) 426-8255 ext.: 5285

NAME OF PLAN                                                       Mason County PUD 3 Healthcare Plan

PLAN SUPERVISOR                                                Pacific Underwriters

                                                                                    P. O. Box 66040

                                                                                    Seattle, Washington 98166

                                                                                    1-800-562-5226

           

PARTICIPANTS                                                        Eligible employees, retirees, elected and

                                                                                    appointed officials of Mason County PUD 3

EFFECTIVE DATE                                                   January 1, 2015

GROUP NUMBER                                                    PURMS11

EMPLOYER IDENTIFICATION NUMBER             91-1259796

PLAN NUMBER                                                        11

CONTRIBUTION REQUIRED                                 Employee Coverage - Yes

                                                                                    Dependent Coverage – Yes

                                                                                    Retirees – Yes

SUMMARY PLAN DESCRIPTION                          This document is the summary Plan Description

                                                                                    required by Washington Administrative Code

                                                                                    (WAC) Chapter 236-22-034.

This booklet is the Summary Plan Description and has been prepared in accordance with the Revised Code of Washington 48.62 and the rules promulgated thereunder by the State of Washington, Department of General Administration, Division of Risk Management to become a part of the Washington Administrative Code (WAC) Chapter 236-22.  This booklet and any Amendments constitute the Plan Document for this benefit plan.  This Plan is maintained for the exclusive benefit of the Plan Participants and each Participant’s rights under this Plan are legally enforceable.  The Plan Administrator has the right to amend this Plan at any time.  The Plan Administrator will make a good faith effort to communicate to the Plan participants all Plan Amendments on a timely basis.

This group health plan believes this plan is a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act).  As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted.  Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing.  However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits. 

 

Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at 360-426-8255.


MASON COUNTY P.U.D. 3

SELF-INSURED MEDICAL PLAN BOOKLET

TABLE OF CONTENTS

                                                                                                               PAGE NO.

CHOOSING A MEDICAL PLAN.. 1

ELIGIBILITY.. 1

ENROLLMENT. 3

WHEN PLAN COVERAGE BEGINS.. 4

WHEN PLAN COVERAGE ENDS.. 4

YOUR OPTIONS FOR CONTINUING BENEFITS.. 4

RELEASE OF INFORMATION.. 7

HIPAA Privacy Rules.. 7

COORDINATION OF BENEFITS PROVISIONS.. 9

APPROVED PROVIDERS AND FACILITIES.. 13

USING PREFERRED PROVIDERS.. 15

SERVICE AREA LIMITATIONS.. 15

MEDICAL REVIEW REQUIREMENTS.. 16

DEDUCTIBLE.. 16

DEDUCTIBLE CARRYOVER.. 16

AMOUNTS NOT CREDITED TOWARD THE DEDUCTIBLE.. 16

CO-PAYMENTS.. 17

EMERGENCY ROOM CO-PAYMENT. 17

WHAT THE PLAN PAYS AND WHAT YOU PAY.. 17

OUT-OF-POCKET EXPENSE LIMIT. 17

FILING A CLAIM:  WHAT TO DO AND WHAT TO EXPECT. 18

ADDITIONAL INFORMATION ON PLAN ADMINISTRATION AND BENEFITS.. 19

SCHEDULE OF BENEFITS.. 24

MEDICAL BENEFITS.. 24

MENTAL TREATMENT. 25

REHABILITATION SERVICES.. 25

PRESCRIPTION BENEFITS.. 26

OptumRX Client Based Network pharmaceuticals.. 26