Tuesday, January 31, 2023

Frequently Asked Health Care Questions


Q.

When and how do I become eligible for coverage?

A.

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. You have up to three consecutive months in which to build these hours. The Plan uses an advanced eligibility. For example, if you worked a total of 360 hours in Feb, Mar and Apr and these hours were reported and paid for by your employer in May, your eligibility would begin in June.

Q.

Once I am eligible, how long will I be covered?

A.

You will be covered so long as the hours reported and paid in by your employer each month total at least 120. For example, hours worked in May would be reported and paid in June; these hours would provide your coverage in July.

Q.

How does my reserve account work?

A.

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.

Q.

Is there a limit to the number of hours that I can have in my reserve account?

A.

Yes. The maximum number of hours that you can have in your reserve account is 360.

Q.

What are my coverage plan options?

A.

For medical coverage, you have a choice of two plans: a self-funded PPO plan or Kaiser. The dental plan is also self-funded, and vision benefits are provided through Vision Service Plan.

Q.

Which plan is better?

A.

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.

Q.

Does my plan have chiopractice/specialist coverage?

A.

Yes. Please refer to your summary plan description for details

Q.

How do I enroll in my chosen plans?

A.

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 BeneSys 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.

Q.

How do I add or delete dependents on my health plans?

A.

You can add or delete a dependent by printing and completing an Add/Delete Dependents Form and mailing it to BeneSys 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 BeneSys directly for this form.

Q.

How/When can I change plans?

A.

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 BeneSys Administrators when the open enrollment period begins.

Q.

Who should I contact if I have a question about a claim?

A.

Please call BeneSys Administrators at (888) 208-0250 with any claims questions.

Q.

Can my provider bill me for the PPO discount?

A.

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.

Q.

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?

A.

If you are in the PPO plan, you can get a list of providers close to you at www.blueshieldca.com/networkPPO. Kaiser participants can obtain information on providers at www.kaiserpermanente.org.

Q.

I need to fill my prescriptions – what pharmacy can I use?

A.

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.

Q.

I tried to pick up my prescription but the pharmacy told me that I need “prior-authorization.” What should I do?

A.

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 BeneSys Administrators.

Q.

Do I need an ID card for medical and dental?

A.

If you are in the self-funded PPO plan and visit a provider who is in the Blue Shield of California Network, you do need to bring your Blue Shield of California PPO card to your medical appointment. Kaiser participants have ID’s that are issued by Kaiser when they are enrolled. These must be used for all medical appointments. If your dentist is an Aetna dental PPO provider you will need to bring your dental ID card with you for dental appointments.

Q.

Does the dental plan have a PPO?

A.

Yes. Effective May 1, 2014, you and your eligible dependents have access to the Aetna Dental Preferred Provider Organization (PPO). Your dental benefits have not changed, but your dental benefits will go farther if you use a PPO dentist. To find an Aetna PPO dental provider, or to determine if your current dentist is an Aetna dental PPO provider, log onto: www.aetna.com/docfind/custom/aetnadentalaccess.

Q.

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?

A.

If there’s ever a question regarding your eligibility, contact BeneSys Administrators. We’re here to help you sort it out.

Q.

I received a COBRA/Termination letter. Why did I get this notice and what do I need to do?

A.

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 BeneSys Administrators within 60 days of the date of your Qualifying Event.

Q.

Self-Payment Rule

A.

The Plan has a "self payment" rule under which a qualified participant who would otherwise lose coverage may continue eligibility by making self-payments for a maximum of two continuous months in a calendar year. The self-payment rate is lower than the premium for COBRA continuation coverage, although the self-payment coverage period runs concurrently with any COBRA coverage period to which the participant is entitled. Participants who could be eligible to make a self-payment to continue coverage under this rule will be notified by the Administration Office of the qualification requirements, the monthly rate and the payment due date.

Q.

I'm on disability/worker's comp or FMLA. How do I continue my coverage?

A.

The Trust offers disability coverage for a specified duration. You should contact BeneSys 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.

Q.

I am going to be working outside the state of California for a few months. Will this affect my coverage?

A.

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.

Q.

I am enrolled in an HMO (Kaiser). Would I still have coverage if I work outside of California?

A.

Kaiser offers 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.

Q.

If I change my coverage because I’m traveling, will my dependents’ coverage change, too?

A.

Yes, any changes that you make in your plan will apply to your dependent’s coverage.

Q.

What about my dental and vision coverage?

A.

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.