FORD MOTOR COMPANY Salaried Active Employeesford.heritagevisionplans.com/handbook.pdf · FORD MOTOR...

FORD MOTOR COMPANY

Ford Vision Benefit Web Site: www.heritagevisionplans.com/ford

Vision Benefit Plan | Certificate of Coverage

Salaried Active EmployeesFORD MOTOR COMPANY

FORD MOTOR COMPANY

Table of Contents

Scope of CoveragePreferred Pricing DiscountWhat's Not Covered

SECTION II USING YOUR BENEFIT PLANUsing a Network ProviderUsing an Out-of-Network ProviderClaims AppealsUnresolved Concerns

FREQUENTLY ASKED QUESTIONS

GLOSSARY OF EYEWEAR TERMS

page 3page 4page 4

page 5page 6page 7page 7

page 8-10

Heritage Vision Plans 1

WELCOME TO HERITAGE VISION PLANS

FORD MOTOR COMPANYBENEFIT PLAN

SECTION I

page 2

MEMBER RIGHTS/PRIVACY PRACTICES

Different Types of Prescription LensesEyeglass Lens MaterialsEyeglass Lens Coatings and Options

page 11page 12page 13

page 14

In t roduct ion

Heritage Vision Planshas developed this guide to help you receive maximum value fromyour vision benefit. Thishandbook covers important topics such as:what services are covered, accessing aprovider, filing a claim,and member rights andprivacy practices.

Heritage Optical 2

WELCOME Ford Motor CompanyEmployees !

We are glad to have you as members of the HeritageVision Plans family. Heritage is a vision benefit management company that is dedicated to providingexceptional service, world-class quality and an extensiveprovider network.

Heritage is committed to the quality, reliability andservice excellence that have made us successful since1975. Our goal is to provide you with the best in eyecare and service.

We are providing this booklet to enable you and your covered dependents to make the best possible use of yourvaluable vision care benefit. If you have questions that arenot answered here, please call us toll-free at 1-888-322-0919, or e-mail us at [email protected].

Cordially,


Heritage Vision Plans, Inc.

Heritage Optical 3

Your Scope of Coverage is determined by Ford. Thissection of the Vision Benefit Handbook will explainyour plan benefit. The following chart indicates whatservices are covered, how often each covered servicecan be used, what you can expect to pay when receivingservices from an in-network provider and what yourreimbursement amounts will be when receivingservices from an out-of-network provider.

Sect ion I


FORD MOTOR COMPANY BENEFIT PLAN

EligibilityYour eligibility and/or your dependent(s) eligibility to par- ticipate in this Plan is determined by Ford Motor Company.

Scope of Coverage

2You are eligible for contact lenses OR glasses, not both, in any plan year.

1Exam and Materials Benefit Frequency is once per Plan Year (January 1

st – December 31

st)

SERVICES COVERAGE

FREQUENCY IN-NETWORK COVERAGE

OUT-OF-NETWORK REIMBURSEMENT

Comprehensive Eye Exam

(Does not apply to Professional fees for Contact Lens Fitting) Once per Calendar Year1 $10.00 Co-pay,100% Covered Reimbursed up to $30.00

Frames: (Choice of One)

Standard Frames

(All frames up to $125.00 Retail)

Once per Calendar Year1

$0.00 (100% covered, No Co-pay)

Reimbursed up to $30.00

Premium Frames

(All frames over $125.00 Retail)

$125.00 Retail Allowance, No Co-pay

A 20% Preferred Pricing Discount will be applied to all frame costs over $125.00


Covered Lenses / Per Pair: (Choice of One) Covered Material = Plastic

Single Vision

Once per Calendar Year $15.00 Co-pay,100% Covered


Bifocal Reimbursed up to $35.00

Trifocal Reimbursed up to $40.00

Progressive

“Standard”


$15.00 Co-pay,100% Covered


“Premium” Member pays “upgrade” expenses over covered

“Standard” Progressive ($15.00 Co-Pay Applies)

25% Discount applies to member’s balance

Covered Lens Options and Upgrades

U.V. Protection

Once per Calendar Year1 100% Covered, No Co-pay

N / A

Tint N / A

Polycarbonate N / A

Contact Lenses: (in lieu of eyeglasses)

● The Contact Lens Benefit is in addition to the Comprehensive Eye Exam.

● The Covered “Standard Contact Lens Fitting Fee” is only applicable if contact lenses are selected as the material benefit.

Standard Contact Lens Fitting2


$0.00 (100% covered, No Co-pay)

N / A

Elective / Cosmetic Contact Lenses2

(All Lens Types including Disposables) $105.00 Retail Allowance, No Co-pay

(Member pays all CL expenses over $105.00) Reimbursed up to $50.00

Medically Necessary2 Contact Lenses & Fitting

(Contact Lenses Prescribed to treat specific Medical Conditions or Diseases of the eye)

$15.00 Co-pay,

Then covered in full up to ($250) Approved U&C Amount

(Requires Prior Approval & Review for Medical Necessity)


Heritage Optical 4Heritage Vision Plans 4

from Heritage Participating Providers, on:

These Discounts may not be combined with any otherdiscounts or promotional offers, and the discounts donot apply to professional services (except Lasik Surgerydiscount) rendered by the provider or to contact lenses.

What’s Not Covered

Products and services not covered under the planinclude:

· Non-prescription lenses· Two pairs of glasses instead of bifocals· Lenses and frames furnished under this plan, which are

lost or destroyed· Parts or repair of frame not covered under

manufacturers' warranty· Medical or surgical treatment of the eyes, with the

· Drugs or medications· Corrective vision services, treatments, and materials

of an experimental nature· Services not visually necessary· Industrial (3mm) safety lenses and safety frames

with side shields· Any services not specified in Ford Motor Company's

Scope of Coverage

exception of the discount for Lasik Surgery.

Retail prices may vary by provider location.

Non-covered Lens Options and Material Upgrades

25% Discount off Retail Prices

2nd Pair of Prescription Eyeglasses or Sunglasses

25% Discount off Retail Prices

Lasik Surgery 15% Discount on retail fee

charged at designated locations 2.

2 Designated Lasik Provider Locations can be found at www.heritagevisionplans.com/ford

Preferred Pricing Discounts

Members will receive a Preferred Pricing Discount,

Sect ion I I

As a Heritage VisionPlans member, youwill maximize benefitsand reduce out-of-pocketcosts by choosing to visitan In-Network Provider.

Heritage Optical 5

USING YOUR BENEFIT PLAN

Using a Network Provider

Here are the steps to take:

1. Select a doctor/provider from the list of network providers. The l ist can be accessed on ourWeb si te: www.heritagevisionplans.com/ford or bycalling our Interactive Voice Response (IVR) Systemtoll-free at: 1-800-352-5667. The Interactive Voice Re-sponse System is available seven days a week, 24hours a day.

2. Make an appointment with the doctor/provider of yourchoice. When calling to make an appointment, identifyyourself as a Heritage Vision Plans member and your group as: Ford Motor Company - Salaried Employ- ees, Retirees and Surviving Spouses.. The doctor will

3. The doctor/provider will verify your eligibilityand/or eligibility of dependents.

4. When the examination is complete and you and/oryour eligible dependents have been fitted for any neces-sary glasses or contact lenses, the doctor/provider willexplain any additional charges you may have to pay.

5. The doctor/provider will take care of all the paper-work. There are no claim forms for you tocomplete.


ask for your ID number and (Patient's) Birth Date.

Using an Out-of-Network Provider

You do have the option of visiting an out-of-networkprovider. If you choose this option, follow these steps:

1. Make an appointment with the doctor/provider ofyour choice.

2. When the examination is complete and you and/oryour eligible dependents have been fitted for any nec-essary eyeglasses or contact lenses, you will pay thefull charges for the exam and eyeglasses or contacts.

3. You will need to request an itemized receipt from the doctor/provider containing the following information:

· Ford Member's name and mailing address· Ford Member's ID number· Ford Motor Company identified as the plan sponsor· Patient's name, date of birth and relationship

to the Ford Member· Service and material received and dates

received· Type of lenses the patient received (single

vision, bifocal, trifocal, Progressive, etc.)

4. Mail the itemized receipt to:Heritage Vision Claimsc/o National Vision Administrators


P.O. Box 2187

The itemized receipt serves as your claimsform for reimbursement.

Clifton, NJ 07015

To be considered for reimbursement, claims must befiled within six months of the date services were completed.

5.

ATTN: Ford Vision Claims Reimbursement

6. the total of all applicable amounts listed under the out-of-network reimbursement column in the chart on Page 3 of of this booklet.

Claims Appeals

If a claim is denied, in whole or in part, Heritage willnotify you of the reasons for denial. Within 60 daysafter the date of the denial notice, you may make awritten request for review of the denial. The requestmust include any and all supporting documentation.The claim will be reviewed and you will be notified ofthe decision. Submit claim appeals to:

Heritage Vision Plans, Inc.ATTN: Claims Appeal Manager One Woodward Avenue, Suite 2020Detroit, MI 48226

Unresolved Concerns

resolution of any customer service issue you may have,please contact your Human Resources Department representative. After exhausting all avenues to haveyour concerns satisfactorily addressed, you may contact:

Health Plans DivisionDepartment of Insurance and Financial Services (DIFS)611 W. Ottawa, Third FloorP.O. Box 30220

Sect ion I I cont inued


If you are not satisfied with Heritage Vision Plans'

Heritage will send you a reimbursement check for up to6.

Lansing, MI 48933


Q: Do I need an ID card?A: No, you do not need an ID card. When you call

for an appointment with a provider, the providerwill verify your eligibility. The provider will ask foryour Member ID number, which is your socialsecurity number, and the Patient's Date of Birth.

Q: How can I obtain a list of vision careproviders in your network?

A: Heritage Vision Plans offers a provider locator onour Web site: www.heritagevisionplans.com/fordand by calling our toll-free number: 1-800-352-5667.

Q: Where do I get a claim form to submit forreimbursement?

A: If you visit an in-network provider, there is no claimform to submit. The provider will handle all of thepaperwork and will submit the claim. If you visit anout-of-network provider, you must get an itemizedreceipt from the provider and submit that receipt toHeritage Vision Plans for reimbursement. Thereceipt will serve as the claim form. Please seePage 6 for a complete description of what theitemized receipt must contain.

Q: Where do I send my itemized receipt forreimbursement?

A: Send the itemized receipt to: Heritage Vision Claimsc/o National Vision AdministratorsATTN: FORD Vision Claims ReimbursementP.O. Box 2187

FAQ


web site: www.heritagevisionplans.com/ford


vider based on the following formulary:

Example:A Frame with an 84.00 wholesale cost would bepriced as follows:

84.00 wholesale cost50.00 frame allowance

34.00 difference

34.00 difference plus 20% ( 6.80) 40.80.The patient would be responsible for 40.80.

Q: How does the contact lens benefit work?

A: Your in-network plan covers all contact lens (non-medically necessary)costs up to 105.00 every plan year. The contact lens fit-ting fee is covered under the benefit, and the contact lensesare covered up to 105.00 every plan year.

Q: What are medically necessary contact lenses?

A: Medically necessary contacts are prescribed to correct thebetter eye to 20/70 due to:

1) cataract surgery2) extreme visual acuity problems not correctable with

spectacle lenses3) significant anisometropia4) keratoconus

Prior approval is required for medically necessary contactlenses.

Frames exceeding the plan allowance (Premium Frames)

Q: How does the wholesale pricing apply to the Premium Frame Allowance?

outlined in the Ford Vision Plan are charged by the pro-A:

$

Q: Do all optical locations have the same


Q: Do I need an ID card?A: No, you do not need an ID card. When you call

for an appointment with a provider, the providerwill verify your eligibility. The provider will ask foryour Member ID number which is your SocialSecurity Number.

Q: How can I obtain a list of vision careproviders in your network?

A: Heritage Vision Plans offers a provider locator onour Web site: www.heritagevisionplans.com and bycalling our toll-free number: 1-800-604-0410.

Q: Where do I get a claim form to submit forreimbursement?

A: If you visit an in-network provider, there is no claimform to submit. The provider will handle all of thepaperwork and will submit the claim. If you visit anout-of-network provider, you must get an itemizedreceipt from the provider and submit that receipt toHeritage Vision Plans for reimbursement. Thereceipt will serve as the claim form. Please seePage 6 for a complete description of what theitemized receipt must contain.

Q: Where do I send my itemized receipt forreimbursement?

A: Send the itemized receipt to: Heritage Vision PlansATTN: Instaset Claims Reimbursement18984 Livernois Avenue, Suite BDetroit, MI 48221

FAQ

frames to choose from?

A: No, the frames will differ by location, but each loca-tion will have a wide variety of styles to choose from.

Clifton, NJ 07015


Q: How can my present doctor join the network?

A: You may refer your doctor to us for inclusion in our network. Request that your doctor contact our Director of Provider Relations at 1-888-322-0919 ext. 1506 for an application packet, or e-mail: [email protected]

Q: Is Lasik a covered or partially covered benefit?A: Ford Motor Company members receive a 15% dis-

count on Lasik Surgery at designated locations

only. The locations can be found on our

Q: How do I know which of the toll-free numbers listed in this book to use?

A: If you need information regarding eligibility orprovider locations, use the 1-800-352-5667 tollfree number. This will connect you to the CustomerService Center or IVR system.

FAQ cont inued


bursed the retail amount charged by the provider.page 6-7 of this member handbook. You will not be reim-out-of-network reimbursement procedure outlined onfiling the claim for reimbursement you must follow theschedule on page 3 of this member handbook. Whenaccording to the out-of-network reimbursement rate in theof a retail sale or promotion, you would be reimbursed

If you decide to pay an in-network provider for servicesout of your own pocket, for example, to take advantage

A:

sed? How much money would I be reimbursed?vices instead of using my benefit, can I be reimbur-

Q: If I decide to pay an in-network provider for ser-

For all other member service needs, please use the 1-888-322-0919 toll free number. This will connectyou to the Heritage Vision Plans administrative offices.


Q: Do all optical locations have the sameframes to choose from?


Q: How can my current doctor join the network?


Q: Can I get both contact lenses and glasses?A: You are eligible to receive contact lenses OR glass-

es in the same Plan Year as a covered benefit.






For all other member service needs, please use the 1-888-322-0919 toll free number. This will connectyou to the Heritage Vision Plans administrative offices

FAQ cont inued
















vider based on the following formulary:

Q: How does the contact lens benefit work?

A: Your in-network benefit covers all contact lens (non-medicallynecessary) costs, up to 105.00, every plan year. Thecontact lens fitting fee is also covered, at 100% in-network,under the benefit every plan year. Out-of-network benefits

Frames exceeding the plan allowance (Premium Frames)

Q: How does the wholesale pricing apply to the Premium Frame Allowance?

outlined in the Ford Vision Plan are charged by the pro-A:

for contact lenses provide for a reimbursement of up to $50.00 every plan year. Contact lens fitting fees are notcovered under the out-of-network benefit.

$














Q: What are medically necessary contact lenses?

A: Medically necessary contacts are prescribed to correct thebetter eye to 20/70 due to:

1) cataract surgery2) extreme visual acuity problems not correctable with

spectacle lenses3) significant anisometropia4) keratoconus

Prior approval is required to be eligible for the medicallynecessary contact lenses benefit.

Heritage Optical 5

Q: Can I get both contact lenses and glasses?You are eligible to receive contact lenses OR glasses inthe same Plan Year as a covered benefit.


DIFFERENT TYPES OF PRESCRIPTION LENSES


Based upon the particular eyesight disorder, different types of

Single Vision Lenses

corrective lenses are prescribed. As a rule, there are 4 types ofprescription lenses: Single Vision, Bifocal, Trifocal, and Progressive.

Single Vision lenses have only one viewing area throughout thelens. This corrected area can be for far distance, near distance, or reading.

Bifocal Lenses

Bifocals (meaning a lens with two points of focus, usually one

commonly prescribed multi-focal lenses.

A small portion of the bifocal eyeglass lens is reserved for thenear-vision correction. The rest of the lens is usually a distance

for far distance and one for near distance) are some of the most

correction, but may have no correction at all if the wearer hasgood distance vision.

Trifocal Lenses

Trifocal lenses are lenses with three points of focus: usually fordistance, intermediate and near. Trifocals have an added seg-ment above the bifocal for viewing things in the intermediate

zone: about an arm's length away. Computer terminals are

typically in the intermediate zone.

Progressive Lenses

Progressive lenses correct vision for multiple distances without the visible segment lines seen in bifocal or trifocal lenses. Insteadthey have a graduated section in which the power of the lens

the wearer to see clearly at all distances.

progresses smoothly from one prescription to the other, allowing

Glossary of Eyewear Terms


The Eyewear Terms in this Glossary are provided for informational purposes only. They are not meant to reflect actual covered benefits under your vision plan.

Please refer to page 3, of this Handbook, for your covered benefits.


The Eyewear Terms in this Glossary are provided for informational purposes only. They are not meant to reflect actual covered benefits under your vision plan.

Please refer to your covered benefits starting on page 3 of this Handbook.

EYEGLASS LENS MATERIALS

Plastic remains the most popular lens material for eyeglasses in the

Plastic Lenses

United States, accounting for nearly 50% of all lenses sold. Plasticis generally regarded as the economy choice in lenses. It offers good optical clarity at a lower price point. Due to thickness, it isnot typically recommended for higher prescription powers.

Polycarbonate Lenses

Polycarbonate Lenses are the most durable of all lenses. Theselenses are over ten times more impact resistant than regular plastic.

eyewear (up to 40% thinner and 30% lighter than standard plasticlenses). Polycarbonate remains a good choice if you want the safest

and/or lightest lenses possible. It is also an excellent material choice

They are also one of the lightest, thinnest lens materials used in

Choosing the right lens material for your eyeglasses is animportant decision, and there are several options.

Hi Index lenses range from 20% to 65% thinner than plastic lenses prescriptions that want the thinnest, most attractive lenses possible.Hi Index lenses are an excellent alternative for patients with higher

(depending on the refractive index). The higher the refractive index,

The Trivex lens is a lightweight, impact resistant material much likepolycarbonate. It offers the added benefits of lower visual distortion, better optics, and inherent U.V. Protection. Trivex is a great substitute for polycarbonate lenses in prescription sunglasses because Trivexcan be easily tinted, whereas polycarbonate cannot.

Glossary of Eyewear Terms( c o n t i n u e d )

for children.

Trivex Lenses

the thinner the lens (and typically the higher the cost).

Hi Index Lenses


EYEGLASS LENS COATINGS AND OPTIONS

Plastic Lenses

of the lightest, thinnest lens materials used in eyewear (up to 40%

You'll likely be given different choices in eyeglass lens coatingsand other optical options. Here

The material in plastic lenses is relatively soft and is easily

Scratch Resistant Coating

scratched if it is not coated with scratch-resistant coating. Thiscoating, a much harder plastic compound, is applied to the lenssurface. The "Scratch Coat" greatly increases the lens' resistanceto scratches and abrasions, however it too can be scratched.

Anti-Reflective or AR Coating

Anti-Reflective Coatings help reduce the reflection on the lenses.When driving (day or night), or using the computer, they reduce the glare and lessen strain on the eyes. What you see is bothclearer and sharper. AR Coating also cosmetically enhances the lens, making the lens almost invisible. Your eyes, not the glasses, become the focus of attention.

Ultra-Violet or UV Coating

UV Coating helps protect the eyes from the harmful damagecaused by the sun. This protection helps the eyes tolerate bright sunlight and softens harsh light without making the glasses seem darker. (Note: Both Polycarbonate and Trivex lenses have built- in Ultra-Violet protective properties.)

Photochromic or Transitions Lenses

levels of sunlight. "Transitions" is the most well-known brand in the category of Photochromic lenses. When worn indoors they are " " virtually clear. When worn outside they change to a dark color.

Photochromic lenses change from light to dark through changing

" "

" "

There are many different choices in eyeglass lens coatings andother optical options. These coatings and options can enhancethe performance and appearance of your eyeglass lenses.

Glossary of Eyewear TermsGlossary of Eyewear Terms( c o n t i n u e d )

Polarized Lenses

Polarized Lenses block out virtually all Ultra-Violet Rays. Theselenses help to eliminate haze and glare, while increasing visibility.


Heritage Optical

If you would like to request a copy of our MemberRights and/or Notice of Privacy Practices, please con-tact us at:

Plan AdministratorHeritage Vision Plans, Inc.One Woodward Avenue, Suite 2020Detroit, MI 48226Phone: (888) 322-0919Fax: (313) 863-1189Email: [email protected]

Provider Information

Information about any participating provider isavailable from Heritage Vision Plans at the above listed address.

Member R ights and Respons ib i l i t ies/ Pr ivacy Pract ices

Member Rights and Responsibilties

Non-Discrimination

Heritage Vision Plans does not discriminate on the basis of race, color, creed, national origin, residence within the approved service area, lawful occupation, sex, handicap, or marital status.

Members may be required to cooperate in the·subrogation and coordination of benefits.

Benefits may not be assigned.

Members shall notify their employer in case ofaddress change.

Members shall have the right to inspect and re-view their own medical records

·

·

·


One Woodward Avenue, Ste. 2020 Detroit, MI 48226

1-800-352-5667 www.heritagevisionplans.com/[email protected]

Corporate Office

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