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BENEFITS SUMMARY

Click here to download PDF copy of the Summary Plan Description

Explanation of a Summary Plan Description (SPD)

This website contains the Summary Plan Description (SPD) for the MILA National Health Plan. It will provide detailed information about the Plan and its many benefits, including medical coverage, dental coverage, vision coverage, behavioral health coverage (including the Member Assistance Plan and treatment for mental illness and substance abuse) and prescription drug coverage. Read the sections which affect your benefit coverage; share the SPD with your family.

MILA National Health Plan

Active Members and their eligible dependents generally will be covered during the calendar year in the Premier, Basic or Core Plan depending upon the credited hours which the Member earned during the prior Contract Year which expires each year on September 30th. Pensioners and their eligible dependents who qualify for health plan benefits in retirement based upon the rules explained later in this book will be covered in the Premier or the Basic Plan until they are eligible to enroll for Medicare benefits. Thereafter, they will be covered in the MILA Medicare Wrap-Around Plan.

Overview of MILA National Health Plan

Medical, behavioral health and prescription drug expenses are uniformly covered in all four Plans (Premier, Basic, Core and MILA Medicare WrapAround Plans) because the MILA National Health Plan is a single unified program. This uniform coverage applies to all expenses unless the Plan specifically states that there is a difference. The main difference between the Plans is the Member’s portion of the benefit expense when a covered charge is incurred. For example, deductibles, coinsurance and copays differ from Plan to Plan. In addition, the Basic and Core Plans only cover In-Network medical and behavioral health benefits. Similarities exist in the following broad general areas of the program:

  • The Plan is self-insured. It is funded by contributions that have been made by employers who are parties to the Master Contract in compliance with the terms of that contract. Additional contributions have been made by Participation Agreement employers at a rate determined by the MILA Trustees and by COBRA participants. All contributions are held in trust in the MILA Managed Health Care Trust Fund for the sole and exclusive benefit of MILA participants and their beneficiaries as determined by the Plan.
  • Benefits provided by network contracted providers (known as network benefits) are the same in all Plans – doctors, hospitals, laboratories and testing facilities, behavioral health counselors and pharmacies.
  • The Claims Administrators are as follows: Cigna manages medical networks and claims; Aetna manages dental networks and claims; EyeMed manages vision networks and First American Administrators (FAA), a wholly owned subsidiary of EyeMed Vision Care, manages claims; Cigna Behavioral Health (CBH) manages behavioral health networks and claims, and CVS Caremark manages prescription drug networks and claims.
  • The Member Assistance Plan (MAP) provides a broad set of programs to assist Plan participants with a whole range of issues. Many people think of the MAP as providing the main access point for the Behavioral Health programs. Although this is true, one can also access the Behavioral Health program directly by calling a provider or through referral from one’s medical provider. However, the MAP can also help with many other problems. For example, it can provide information about child care and elder care providers, it can help with financial counseling on a whole range of issues from mortgage selection and evaluation to budgeting and household financial management and it can assist with marriage counseling and workplace problem resolution. Many other issues may also be addressed by the MAP counselors. Any person in the Member’s household may access the MAP directly by calling the MAP counselor. If you are uncertain as to whether a particular problem might be addressed by the MAP, call a MAP counselor and ask.
  • Covered charges and benefit exclusions are the same throughout the program except:
    • In the Premier Plan and the MILA Medicare Wrap-Around Plans, medical and behavioral health benefits are covered both In-Network and Out-of-Network.
    • In the Basic and Core Plans, only In-Network medical and behavioral health benefits are covered.
    • In the MILA Medicare Wrap-Around Plan, Medicare provides the network as the primary payer of benefits except in the extremely rare circumstances when Medicare does not cover the service or supply but the Plan does.
  • Plan benefit limits apply throughout the program. If you change benefit Plans during the year, annual Plan limits transfer into the new Plan. This happens infrequently but it might happen if you retired or if your dependent lost eligibility and elected COBRA continuation coverage in another lower cost MILA Plan.
  • The requirements for medical management are the same in the Premier, Basic and Core Plans – that is, the requirements for precertification of:
    • a medical procedure or service;
    • an admission to a hospital or other institution, for concurrent review of a hospital or institutional confinement by the appropriate Claims Administrator; and
    • for prior authorization of a limited number of prescription drugs.
    • In the MILA Medicare Wrap-Around Plan, Medicare procedures govern when Medicare covers a service or supply. Otherwise, MILA’s Claims Administrator’s procedures apply.

Grandfathered Plans: Affordable Care Act (ACA)-
Important Information

The MILA Trustees believe the Premier Plan, the Basic Plan and the Core Plan are “grandfathered health plans” 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 MILA Executive Director. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or access information online here. This website has a table summarizing which protections do and do not apply to grandfathered health plans.

The MILA Medicare Wrap-Around Plan is not a Grandfathered Plan. Rather, it is exempt from the provisions of the Affordable Care Act because it covers only retired persons and their dependents and its benefits are provided to supplement those available from Medicare, Parts A & B.