Q: Why do I have to enroll again this year?
A: The pricetags for the Spectrum retiree medical/prescription drug program change each year and we wanted to provide you with the opportunity to review and possibly change your enrollment choices if you wish. Please remember, if you do not enroll in one of these plans, Cooper will assign you coverage and you will be billed accordingly. If you previously chose No Coverage, you will need to select No Coverage again.
Q: Is there someone I can speak with who can help me with enrollment?
A: Yes. If you need help or have questions about your benefits or how to enroll, you can speak with a Cooper Spectrum representative at the Call Center during open enrollment, between 11 a.m. and 7 p.m. EST, Monday through Friday.
Q: What if I change my mind about my enrollment choices?
A: You may change your coverage choices as many times as you wish until midnight on the last day of open enrollment. After that date you cannot change your benefit coverage until next year's open enrollment, or when you have a qualified status change. Any change you make must be consistent with your change in family status. You experience a qualified status change if:
Q: How was the cap determined?
A: Cooper set a policy that determined the capped or maximum amount it would pay toward retiree medical. These caps apply to post-1992 Heritage Cooper retirees and post-1990 Heritage Standard Products retirees.
Q: Is there a possibility that Cooper will change my benefits again?
A: As with any employer, Cooper reserves the right to change its benefit plans at any time. We are continuously looking at our benefits to provide affordable access to medical/prescription drug benefits that meet the needs of you and your family and, at the same time, help strengthen our competitive position in the marketplace.
Q: What is the advantage of using an in-network doctor?
A: Providers who participate in the PPO network have agreed to a fee schedule for covered services. Therefore, you will not pay for any charges that may be above the negotiated fee schedule. Additionally, when you receive services from an in-network provider your co-pays and coinsurance levels are smaller than if you went out-of-network.
Q: My physician is not a member of the PPO in my area, can he be added?
A: Yes. Contact the Human Resource Department for a nomination form to complete and submit to Health Design Plus to nominate a physician or go to the Cooper Spectrum website.
Q: I go south for the winter, what zip code will be used for my eligibility for a PPO plan?
A: For retirees choosing the Basic PPO or Premium PPO options, your network is based on your zip code. If you have two residences, you must change your address by calling 1-800-537-9523, x6073 and providing your new address each time you move, so your claims will be processed in the correct network.
Q: What happens if I'm traveling and away from my normal area? Do I fall under the "out-of-area" category if there isn't a doctor who participates in the network?
A: If you are traveling and your need is a true emergency, services will be reimbursed as if you went to an in-network doctor or hospital.
Q: How does the medical deductible work if I have a mix of in-network and out-of-network providers?
A: Amounts accrued towards in-network and out-of-network deductibles cross apply. For example, if you choose the Basic PPO and you had already met your $450 in-network deductible, and then went to an out-of-network doctor, you would need to meet an additional $400 to meet the out-of-network deductible of $850.
Q: Does an office visit cost $25, or $25 plus the applicable co-pay?
A: You pay only the $25 co-pay if you go to an in-network doctor for primary care. This means that $25 is all you would pay for the charges billed as the office call. A specialist office visit requires a $35 co-pay.
Q: Are there co-pays for other services besides office visits?
A: Co-pays apply to office visits, emergency room visits, hospital confinements, outpatient hospital services, and use of urgent care facilities.
Q: Do I still have to pay the higher "brand" charge if my doctor prescribes "name brand" drugs?
A: Yes.
Q: Will I have to pay the brand co-pay for prescription if no generic is available, or only if you demand to get the brand name?
A: Even if only a brand name drug is available you will need to pay the percentage applicable to brand name drugs. However, if a generic option is available but you choose a brand, you must pay the generic co-pay plus the cost difference between the brand and generic drugs. This also applies if a generic is available but your doctor has indicated dispense as written (DAW) on the prescription.
Q: Is pre-certification required from Health Design Plan before medical surgeries?
A: Yes. There is also a list of other procedures requiring pre-certification in the summary plan description. If you fail to obtain pre-certification, there is a fee.
Q: How are diabetic supplies covered?
A: Insulin and needles are covered through the prescription drug plan. Lances and test strips are covered through the medical plan.
Q: How are Chiropractic Visits covered?
A: Chiropractic services are covered to a maximum of $1000 per year. This includes x-rays and manipulations. These services are paid as out-of-area unless the chiropractor is a member of your network. Co-pays do not apply to chiropractic visits, however plan deductibles and co-insurance apply.
Q: Are adult physicals, pap smears, and mammograms covered?
A: Yes.
Q: Are hearing aids covered?
A: No, hearing aids are not covered under any of the medical plan options.
Q: What happens if I become eligible for Medicare in the middle of the year?
A: If you become eligible for Medicare in the middle of the year, you will automatically be sent a new Personalized Enrollment Worksheet (PEW) and you will need to choose coverage from the Medicare (post 1992) options. Your costs will be adjusted accordingly.
Preferred Provider Organization - A network of providers (hospitals, doctors, labs, etc.) who agree to provide healthcare services to participants at discounted fees. When you receive services with "in-network" providers you pay less. You are also covered if you receive services from "out-of-network" providers but you will pay more.
Deductible - The portion of covered charges you pay before the plan pays any benefits.
Coinsurance - The percentage you pay for a medical service; for example, you pay 20% and the plan pays 80%.
Co-pay - A set amount you pay for a medical expense. For example, you pay a $25 co-pay for an office visit.
Out-of-pocket maximum - The maximum amount you will pay for covered medical services in any calendar year. The plan pays 100% of reasonable and customary expenses after you have met the out-of-pocket maximum.