|
|
|
Health FAQ
- When and how do I become eligible for coverage?
You become eligible for coverage the first day of the third month following the month in which 360 hours have been reported and paid into your reserve account. For hours worked between November 2010 and March 2013, you have up to five consecutive months in which to build these hours. The Plan uses an advanced eligibility system. For example, if you worked a total of 360 hours in February, March and April, and these hours were reported and paid for by your employer in May, your eligibility would begin in July.
- Once I am eligible, how long will I be covered?
You will be covered so long as the hours reported and paid in by your employer each month total at least 120. As stated above, the Plan utilizes the advanced eligibility method. For example, hours worked in May would be reported and paid in June; these hours would provide your coverage in August.
- How does my reserve account work?
Hours are reported and paid in by your employer following the month in which they were worked. As stated above, you need to work 120 hours in the work month to be eligible in the coverage month. Any hours in excess of 120 are placed into your reserve account. If in a month, you have fewer than 120 hours reported, you can use any hours in your reserve account to make up the difference.
- Is there a limit to the number of hours that I can have in my reserve account?
Yes. The maximum number of hours that you can have in your reserve account is 360.
- What are my coverage plan options?
For medical coverage, you have a choice of three plans: a self-funded PPO plan, Kaiser or UnitedHealthcare. The dental plan is also self-funded, and vision benefits are provided through Vision Service Plan.
- Which plan is better?
All plans are excellent. You should carefully study the comparisons to determine which plan would suit you and your family best. With the PPO plan, you can visit any medical provider. You will pay less out-of-pocket if you use PPO providers. The Kaiser Plan requires all services to be obtained at Kaiser facilities with Kaiser’s practitioners. UnitedHealthcare is an HMO that contracts with providers. All care must be coordinated through the UnitedHealthcare primary care physician that you choose. Family members may choose different primary care physicians.
- Does my plan have chiropractic/specialist coverage?
Yes. Please refer to your summary plan description for details.
- How do I enroll in my chosen plans?
To ensure that you and your dependents are covered in the NCTI plan, you must complete the Enrollment Form that is sent to you by Alllied Administrators when you first become eligible for coverage. If you wish to enroll in one of the HMO’s, you must also complete the appropriate enrollment form for that HMO.
- How do I add or delete dependents on my health plans?
You can add or delete a dependent by printing and completing an Add/Delete Dependents Form and mailing it to Allied Administrators. Please read the form carefully, as you are required to submit the appropriate documentation, i.e., birth or marriage certificate, divorce decree, etc. If you prefer, you can also contact Allied directly for this form. If you are enrolled in an HMO plan and wish to add or delete a dependent, you must also complete the appropriate form for your HMO.
- My child has reached the limiting age, but he is completely dependent on me for support due to a physical limitation. Is there a way I can extend his coverage?
Yes. If you have a dependent child with a mental or physical limitation, you can continue his coverage provided that the following requirements are met: your child is chiefly dependent on you for support; your child is not capable of self-sustaining employment; and you give us proof of the child’s handicap: (1) not later than 31 days after the child attains the limiting age; and (2) thereafter as the Trustees may require, but not more than once every two years, by completing a Request for Continued Coverage for Incapacitated Child form.
- How/when can I change plans?
The Plan conducts an annual open enrollment. During this open enrollment period, you will have the opportunity to change your medical plan, if you wish. You will be notified by Allied Administrators when the open enrollment period begins.
- How do I file a claim for reimbursement?
You’ll need to fill out a Claim Form. Be sure to complete all sections and attach appropriate documentation. Then, submit the form to Allied Administrators for reimbursement. You can also contact Allied directly for a claims form.
- Is it possible for my physician to submit claims to Allied Administrators electronically?
Yes! If your physician’s office is set up for electronic filing, simply provide Allied’s EDI number: 94177. That’s all the information they’ll need to file claims electronically.
- How will I know if a claim has been paid?
Allied will send you an Explanation of Benefits (EOB) statement whenever a claim has been paid on your behalf. If you utilize PPO providers, Allied will send payment directly to the PPO provider and a copy of the EOB to you that shows all the charge and payment information regarding the claim.
- Can you explain how I should read the EOB?
A sample EOB can be found here. Reading from left to right, top to bottom, the first section displays the health plan name, your masked identification number, and the number assigned to the claim.
Next, you’ll see the employee’s name, the patient’s name, the claims examiner, group number and date the claim was processed.
The next section covers the date(s) of treatment, the three-letter service code and the five-digit Current Procedure Terminology (CPT) code used by the billing provider of service. It also shows how the claim was adjudicated. In our sample EOB, there were two procedures (treatments) on the same day. The Charge Amount column shows what the provider has billed for these procedures. The next column shows if any charges were not covered. In this example, there were charges not covered, and the two-digit reason code is shown next. The PPO Discount is then applied, and the column after that shows the Covered Amount (Charge Amount – Not Covered – PPO Discount). The deductible and any co-pays are then applied. In this example, the calendar year deductible has already been met, and there are no co-pays. The next column in the EOB shows the percentage that the Plan pays. Because this was a PPO provider, the percentage is 90%. Finally, there is the Payment Amount, the amount that will be paid to the provider.
Immediately under this section, is an area containing the patient account number from the doctor’s office (if it is available) and any adjustments or credits made in the event there is other coverage.
The next item is the Patient’s Responsibility section. It is the combination of Amount not Covered, Co-Pay Amount, Deductible and Co-Insurance. This would be the amount that you would have to pay your provider.
The Payment Information box shows who the plan payment was sent to, the date it was sent, check number and amount paid.
The Service Code box defines the three-letter code used on the lines above. The Reason Code box provides an explanation of the two-digit code for why charges were not covered. Finally, the Messages box shows which PPO network was utilized, if any, and your appeal rights.
- Can my provider bill me for the PPO discount?
If you visit a provider who is contracted with the PPO, the provider cannot bill you for anymore than the amount shown under Patient’s Responsibility on the EOB. Billing for any amount greater than that is known as “balance billing,” and this practice is prohibited by California state law.
- I need to see a Doctor, but I don't know who to go to. Do you have a list of doctors near where I live or work?
If you are in the PPO plan, you can get a list of providers close to you at the Anthem Blue Cross Prudent Buyer website. Kaiser participants can obtain information on providers at www.kaiserpermanente.org. If you are enrolled in UnitedHealthcare, you should visit their website www.uhcwest.com.
- I need to fill my prescriptions – what pharmacy can I use?
If you are in the self-funded PPO, you can use any of the hundreds of pharmacies that are contracted with Sav-Rx, the PPO plan’s pharmacy benefits manager. Visit their website at www.savrx.com for a listing of pharmacies in your area. Kaiser participants must have their prescriptions filled at Kaiser pharmacies. If you are a UnitedHealthcare participant, your prescriptions must be filled at a pharmacy that contracts with UnitedHealthcare.
- I tried to pick up my prescription but the pharmacy told me that I need “prior-authorization.” What should I do?
Certain prescriptions require prior authorization from the health plan in which you are enrolled. If you are covered by the self-funded Plan with SavRx your pharmacist will let you know if a prescription needs prior authorization. Most pharmacies will work this through directly with SavRx and your doctor’s office. If this is not the case your physician‘s office simply needs to get in touch with the help desk at SavRx (800-228-3108) or contact Allied Administrators.
- Do I need an ID card for medical and dental?
If you are in the self-funded PPO plan and visit a provider who is in the Anthem Blue Cross Prudent Buyer Network, you do need to bring your Anthem Blue Cross PPO card to your medical appointment. HMO participants have ID’s that are issued by the HMO in which they are enrolled. These must be used for all medical appointments. There are no ID cards for dental benefits, simply provide your dental office with Allied’s phone number, (415) 986-6276, to verify your eligibility and benefits.
- Does the dental plan have a PPO?
No. You can visit any dentist you wish.
- Is there a claim form specifically for dental claims?
There is a Dental Claim Form, which you can bring with you to your next dental appointment. Your dentist can also utilize electronic filing. Simply give your dentist's office Allied's EDI number: 94177.
- I went to my doctor’s appointment today, but I was told that my coverage is terminated. I've been working steadily. Am I covered for the visit?
If there’s ever a question regarding your eligibility, contact Allied Administrators. We’re here to help you sort it out.
- I would like to participate in the Tile Industry Wellness Program. What do I need to do and how much does it cost?
Instructions for joining the Wellness Program can be found here. After you have joined through the website at www.TileWellnessHMC.com, you then fill out a 10-minute Health Risk Assessment (HRA) to determine which module(s), if any, would benefit you. There is no cost to you to participate in this program. In fact, once you have completed the HRA, you will be paid $25.00.
- What is the Health Risk Assessment (HRA)?
The HRA is a 15-minute questionnaire that will help you and your healthcare provider discover the health risks you maybe facing in 2011 and beyond. The HRA offers both immediate and long-term benefits. All you have to do is go on-line to: www.HMCTotalHealth.com and answer a few questions about your lifestyle and other factors that may affect your health. For instance: Have you had a physical exam in the past year? Do you buckle your seat belt every time you drive or ride in a car? When completing the HRA online, you will immediately receive your personalized health report by printing your results!!
- How do I access the HRA?
1. Online: www.TileWellnessHMC.com and follow the simple on-screen instructions.
2. Phone: Call HMC toll free at 888-369-5053. An HMC representative will answer any questions you have about taking your on-line HRA.
- What will the HRA tell me?
Your Personal Health Report will give you a better understanding of your personal health status. It shows you how your lifestyle and daily activities affect your personal health. It will also suggest steps you can take to improve or maintain your health, and it might even help you start a more meaningful conversation with your doctor.
- Will my union or employer be notified of my HRA results?
No! The HRA is strictly confidential. Only you and the Health Professionals at HMC (HMC is an independent contractor that provides health management programs to the NCTI Plan) can see your answers. None of this confidential information will be shared with Employers, the Benefit Fund or the Union Local. We do encourage you to share your results with your physician to follow-up with any recommendations or concerns.
- What are the benefits of taking the online HRA?
The online version is fast and easy. You can do it in the privacy of your home. It is available 24/7, will only take 10 minutes to complete, and you will get instant results.
- I received a COBRA/Termination letter. Why did I get this notice and what do I need to do?
You received this notice because you had a COBRA Qualifying Event. The most common reason for this is the combination of current hours worked and the hours in your reserve account was less than 120 hours. Other COBRA Qualifying Events include divorce, death of the participant, or a dependent child’s reaching the maximum age limit. In each of these instances, you will have lost eligibility. If you wish to sign up for COBRA coverage, you must return the application to Allied Administrators within 60 days of the date of your Qualifying Event.
- What is the short-pay benefit?
Beginning with the May 2011 coverage month (February 2011 work month), if you have at least 80 hours reported by a signatory employer but don’t have enough hours in reserve to total the 120 hours needed for eligibility, you can “buy-up” the difference in hours. For example, you have 80 hours reported and 10 hours in your reserve account for a total of 90 hours. This is 30 hours fewer than you need for coverage. You can pay for those 30 hours yourself at the current contribution rate and obtain eligibility for that month. If you are eligible to make a short-payment, you should Contact Us, and we will let you know the amount due. You must also complete and sign a Short-Pay Notice and Remittance Form. This short-pay provision is set to expire on March 31, 2013.
- What happens if I decide not to make a short payment?
If you are eligible to make a short payment and elect not to do so, your coverage will terminate and you will not be able to make a short payment for coverage ever again.
- I'm on disability/worker's comp or FMLA. How do I continue my coverage?
The Trust offers disability coverage for a specified duration. You should contact Allied Administrators for more information. After the period of disability coverage provided by the Trust at no cost to the member, you can also elect to take COBRA coverage. FMLA coverage is through your employer only, and you must contact your employer to determine what steps you need to take.
- I am going to be working outside the state of California for a few months. Will this affect my coverage?
If you are in the Self-Funded PPO plan, you and your eligible dependents are covered anywhere in the United States. In California, the preferred provider network is the Anthem Blue Cross network. Outside of California, the PPO network is First Health. You can visit their website at www.firsthealth.com to view their providers. If you visit a First Health provider when you are outside of California, your benefits will be paid at the PPO level.
- I am enrolled in an HMO (Kaiser or UnitedHealthcare). Would I still have coverage if I work outside of California?
Both Kaiser and UnitedHealthcare offer urgent care and emergency services for participants who are outside their services areas, which you would be if you’re working outside California. Non-urgent or emergency care must be coordinated through your primary care physician. If you are going to be outside of California for more than 90 days, you may wish to consider changing your coverage to the Self-Funded PPO plan. As a “traveler,” you are allowed to move out of your HMO and into the PPO and return to the HMO when you return to California.
- If I change my coverage because I’m travelling, will my dependents’ coverage change, too?
Yes, any changes that you make in your plan will apply to your dependent’s coverage.
- What about my dental and vision coverage?
Dental coverage is available anywhere in the United States. You can visit any dental provider. Vision coverage is also available throughout the United States with Vision Service Plan.
|