Wednesday, September 18, 2019

Frequently Asked Health Care Questions


Q.

What doctors are covered by the medical plans?

A.

The doctors covered depend on the plan you select.  If you enroll in Kaiser or HMSA, you are assigned a primary care physician when you enroll.  Your primary care physician will refer you to authorized specialists.

If you select the Trust Medical plan you are free to see any licensed provider however, the plan provides much higher benefits for those on the PPO plan when you see a provider in the Premera Blue Card network

Q.

Are my dependents covered under my plan?

A.

Active employees have family coverage at no additional cost.  A covered dependent is outlined below: 

  1. The lawful spouse of the employee. Your spouse is not eligible if you are legally separated.  In the event of the employee’s death, the surviving spouse is eligible so long as they are not re-married.

  2. Children under age 26 who depend on you for support and who are:
    1. A natural child of either or both you or your spouse;
    2. A legally adopted child of either or both you or your spouse; or
    3. The unborn child of a deceased employee or retired employee.
    4. A child "placed" with the employee for the purpose of legal adoption in accordance with state law.  "Placed" for adoption means assumption and retention by the employee of a legal obligation for primary support of a child in anticipation of adoption of such child. However, if adoption is not finalized, the Trust reserves the right to request a refund of benefits already paid for said child.
  3. Children who continue to depend on you for support can continue coverage after they reach age 26 if:
    1. The child is enrolled in a recognized educational institution as a full time student (12 credit hours or equivalent, not less than 8 months of the year) and who has not attained the age of 26.
    2. The dependent child cannot support him or herself because of a developmental or physical disability so long as all the following are met:
      • The child became disabled before reaching the limiting age; and
    3. The child is incapable of self-sustaining employment by reason of developmental disability or physical handicap; and
    4. Within 31 days of the child reaching the limiting age, the employee furnishes proof of disability to the Trust Office. The Trust Office must approve the request for coverage to continue; and
    5. At least once a year, and after the two year period following the child’s attainment of the limiting age, the employee provides the Trust Office with proof of the disability.

An employee’s grandchild who:
  1. Meets the definition of a dependent child; and
  2. For whom the employee is providing the major amount of support; and
  3. For whom the employee has been named as legal guardian by a court of competent jurisdiction; and
  4. Is in the physical custody of the employee.

Dependent eligibility for HMO plans may vary, see the appropriate HMO Plan's benefit booklet.

Q.

What should I do if I get married?

A.

If you get married, print an Enrollment Form,  complete the form to add your spouse to the health plan and mail, fax, or scan and email your documents to the Trust office along with a copy of your marriage certificate. You must submit your updated enrollment within 30 days of your marriage. Your spouse would then be covered as of the day of your marriage. 

If you chose, you also have the opportunity to change health plans at this time.

You may also want to complete a new Beneficiary Form, and include it with your enrollment forms. We need to have an original signature on your beneficiary form, therefore it is recommended that you mail the form to the Trust Office.

Q.

What should I do if I get divorced?

A.

If you become legally separated or divorced, you are responsible for contacting the Trust office to let us know the date of the separation or divorce.  The Trust will need a completed Enrollment Form and a copy of your divorce decree or legal separation before we can terminate coverage for your ex-spouse. If you have a current address for your ex-spouse, please include that information on the enrollment so that we may send him/her a COBRA notice and Certificate of Coverage. 

It is recommended that you complete a new beneficiary form to change the beneficiary for your life insurance and pension plan.  Complete the form, have it signed by a witness (who is not a beneficiary) and mail it to the Trust office.

If you chose, you also have the opportunity to change health plans at this time.

Q.

What should I do if I move?

A.

Please email, mail or call the Trust office to provide us with your new address and we will update our records.  If you move into or out of an HMO or PPO service area you may have to change health plans or have the opportunity to change health plans.

Q.

What should I do if I have a child or adopt?

A.

If you add a member to your family, simply print an Enrollment Form.  Fill out the form in order to add your child to the health plan.  Your child is covered as of the day of your birth or adoption.  Mail the form to the Trust office along with a copy of the birth certificate or court documents.  You may also want to fill out a new beneficiary form, and include and mail it to the Trust office also.

If you so chose, you also have the opportunity to change health plans at this time.

Q.

What should I do if I get legal custody of a child?

A.

If you add a member to your family, simply print an Enrollment Form.  Fill out the form in order to add your child to the health plan.  Your child is covered as of the day of custody.  Mail the form and a copy of the court document granting custody to the Trust office.  You may also want to change your beneficiary form, and mail it to the Trust office also.

If you so choose, you also have the opportunity to change health plans at this time.

Q.

What should I do if there is a death in my immediate family (or I die)?

A.

Contact us at A&I in order to find out how the survivors' benefits may be affected, and the options the survivors' have.  Depending on the circumstances a photocopy of the death certificate may be required.

Q.

What is a reserve account and how much is in mine? How much can I accumulate in my reserve account?

A.

All employer contributions for work you have performed are credited (in dollars) to your reserve account. This is a continuing process. There is no limit to the amount you can maintain in your Individual Reserve Account. Your reserve account allows you to maintain eligibility through continued contributions adequate to fund your selected plan.  You may call the Plan Administrator to determine the dollars in your reserve account.

There is no limit to how much you may accumulate in your reserve account.

Q.
How long will my coverage last if I get laid off?
A.

It depends upon how much money is in your reserve and supplemental accounts.  As long is there is adequate dollars in your reserve and supplemental accounts, you will continue to have coverage.  At that point that you do not have enough money in these accounts to grant a month of coverage, you will be mailed a COBRA notice.

Q.

Have my doctor bills been paid?

A.

If you are enrolled in the Trust Medical plan, your doctor bills are priced by "Premera Blue Cross".  Premera then sends the provider bills to the Trust for processing, then Premera will issue the payments directly to your provider(s). Medical claim information is accessible online at this site by clicking here. (***Please note, all claims with dates of service on or after January 1, 2013 should be initially filed with Premera, dates of service through December 31, 2012 should be filed with Regence Blue Cross.***)

If you are enrolled in Kaiser, Group Health, or  HMSA, your bills will be paid by those plans.  You may contact them at the numbers and addresses listed in our contacts page on this site.

Q.

How do I file a claim?

A.

When you receive care, your doctor's office usually takes care of filing your claim.  However, to ensure your claim is sent to the proper address you must show your doctor's office your ID card.   It is important that you ask that they update their computer records with the claim address information shown on the card.

If you are covered under the Trust Medical Plan and seek services from a PPO or non PPO Provider, your provider will file the claim.  Provider will need to file your claim and send it to:

Premera Blue Cross
Claims Department
PO Box 91059
Seattle, WA 98111-9159

Q.

How do I get a replacement ID card?

A.

If you are covered under the Trust Plan, Contact us at Benesys for medical/RX or dental/vision ID cards.

If you are enrolled in Kaiser or HMSA, you may obtain ID cards directly from the carrier.  You may contact them at the numbers and addresses listed in our contacts page on this site.

Q.

If I quit working or I am terminated, can I cash out the money in my supplemental or reserve account?

A.

No, the reserve account funds will be used to grant you coverage.  The supplemental funds will be used to reimburse for out of pocket expenses or to grant you coverage.

Q.

Is my doctor under the PPO?

A.

Please contact the Premera Blue Card network by calling their toll free phone number 1-800-810-(BLUE) 2583 or visit the Premera web site. Click on the 'Find a Doctor" link, then follow the prompts.  Please be sure to verify with the provider that the provider or facility is currently a preferred provider.

Q.

 How do I get a PPO provider for dental or vision?

A.

If you are on the Trust plan you have the freedom of choice for dental or vision providers.  The PPO network is for medical and pharmacy only.  It is up to the dental or vision provider whether they bill insurance or will require payment at the time of services and you must bill their own insurance. 

Q.

Can I cover my domestic partner if we are not married?

A.

Yes. You may apply for coverage for your domestic partner of the same or different gender.  You and your domestic partner must submit an Domestic Partner Affidavit and declaration that is signed and notarized.  There is a monthly cost that will be deducted as an autopay from your checking or savings account.  At the end of each year you will receive a W-2 with amounts to be claimed on your income taxes, as earnings. 

Q.

What types of charges can I get reimbursed from my Supplemental Account?

A.

Benefits from your Supplemental account include deductibles, co-pay, out of pocket expenses (also known as co-insurance), and various charges that are not covered by the health plan.  The charges not covered by the health plan that can be reimbursed through Supplemental include:

  • Amounts over usual & customary
  • Any dental or orthodontic work over the plan limits
  • Hearing Exams & Aids
  • Dental sealants or fluoride treatment (over age 19)
  • Vision materials and services over the plan limits
  • Orthotic services
  • Routine services not covered
  • Naturopathic services
Q.

What methods are available to claim my Supplemental dollars?

A.

There are two methods available in which you can claim your monies: Early Payment or the Monthly recap method.

Q.

What is Early Payment vs. Monthly Recap Payment?

A.

The Early Payment method is the automatic payment method.  If you are enrolled in this option and you have a health plan in which the Trust processes your claims, The Trust will automatically send you a check when:

  1. You have money in your Supplemental account; and
  2. A&I processes a medical, dental or vision claim on which you are out of pocket some monies; OR
  3. We receive notification from Moda of your prescription charges                                                                    

Your check will include Supplemental dollars you can claim for medical, dental, and vision claims paid by A&I. Any Supplemental check WILL NOT include any of the non-covered expenses, as listed above or in your benefit booklet. 

The Monthly Recap method means that A&I will send you a letter at the end of every month. We tally all your charges processed during the month and if you have Supplemental dollars available, the Trust will send you a recap of all claims paid, along with the amount available for claim in your supplemental account. If you wish to claim a portion or all of the amounts allowable for that month, you must sign the letter and return it to the Trust office (A&I) by the date on the letter (usually within 18 days) and the Trust will then send you a check. 

If your signed form is received past the due date, you will not be able to claim those funds for that month. If you know you will be wanting to claim your funds and you will not be available to complete and return your form, it is your responsibility to make arrangements in your absence. Likewise, if you do not claim the funds, they will remain in your account until further claims are processed.

Q.

How can I be reimbursed if my claims are not processed by the Trust?

A.

If you are enrolled in an HMO plan (Kaiser or HMSA), the Trust does not process your claims, therefore we do not know when you have utilized your benefits and what your out of pocket expenses have been. Therefore, you must submit a supplemental reimbursement claim form with a copy of your explanation of benefits, line item bill, or prescription receipt.  These documents will indicate what the charges were, diagnosis codes, and what your out of pocket expenses have been. Payment will be made based on the funds available. 

Members on HMO's do not have the option of early supplemental or monthly recap. Therefore, you will need to submit your claims within a reasonable amount of time after services are rendered. (30-60 days)

Q.

Where do I get a form for turning in a manual Supplemental claim?

A.

The Supplemental claim form is available on the Forms page.

Q.

Am I able to use my supplemental account for anything other than reimbursement of out of pocket expenses?

A.

Yes. If your Individual Reserve Account is insufficient to grant your coverage, your Supplemental Account will automatically be used to pay for the cost of the plan in which you are enrolled.

The only time the Trust Office will not take the funds from your supplemental account is when YOU have stated in writing that you do not wish supplemental funds used for plan premiums. Therefore, if you receive a notice that supplemental funds were used for coverage, you will need to contact the Trust to indicate you do not wish for those funds to be used for premium that month.

Q.

How do I select Monthly Recap or the Early Payment option?

A.

Open enrollment for supplemental occurs only once each year.  Notice is mailed in January and you are given 30 days in which to respond.

Q.

What is a generic drug?

A.

After the patent expires on a name brand drug, other companies are allowed to manufacture the drug as a “generic equivalent”.  Because the drug can be produced by a variety of manufacturers, and due to this increased competition, the price of the drug decreases.  An example is Tagamet (name brand) and Cimetidine (generic equivalent).

Q.

Is the generic drug the same as the name brand?

A.

Generic drugs are approved by the Food and Drug Administration (FDA*) and contain the same active ingredients as their name brand counterparts.  The generic drug will be of the same dosage form, identical in strength and concentration and be taken in the same way as the name brand drug. 

*The FDA is a US government agency that regulates drug quality, strength and purity.

Q.

Who makes the generic drugs?

A.

Nearly two thirds of all generic drugs are manufactured by the same large pharmaceutical firms that make the name brand drugs and all generic drugs are manufactured according to the same federal regulations.  In fact, several manufacturers make both the generic and name brand versions of the same drug. 

Q.

Why use a generic drug?

A.

To help keep health care costs down. You pay a lower copayment if you chose a generic drug over the name brand drug. 

Q.

What is my co-payment for Preferred vs Non-Preferred Drugs?

A.

Preferred Brand $20/30-day, $40/90-day Non-Preferred Brand $40/30-day, $80/90-day via mail order.
For more information about Preferred or Non-Preffered Brands visit the following website: www.Modacompanies.com

Q.

What should I ask my doctor regarding the prescribed medications?

A.

Inform your doctor that your plan has implemented prescription care management programs. A few prescription drugs may require prior authorization before they can be dispensed. If your prescription requires a prior authorization, your doctor must contact the clinical staff at Moda to avoid delays in your obtaining the medication. Your doctor may also need to contact the clinical staff at Moda Health regarding the quantity he/she is prescribing based on the quantity being prescribed (see next question).

Q.

What are quantity limitations?

A.

Limits as based on the manufacturer’s recommended daily dosage may exist for the number of tablets, patches, inhalers or bottles that will be covered each time a new or refill prescription is dispensed.  Quantity level limits do not restrict the number of refills you may obtain.  If your prescription order or refill exceeds the manufacturer’s recommended daily dosage, your pharmacist will receive a message that Moda Health needs to review your prescription with your doctor.  Your doctor must contact the Moda Health to determine if your medical condition qualifies you to receive the medication as your doctor is prescribing.

Q.

Why are prior authorizations required?

A.

Certainly for cost containment purposes, but also to help ensure that you receive the most effective treatment from specific medications and to ensure appropriate dosing of these drugs.  Your overall health is a concern to the Health plan. 

Q.

What if I'm told the pharmacy cannot fill my prescription?

A.

The pharmacist should explain why the prescription cannot be filled, and provide you with instructions on how to proceed.  Usually, the pharmacy will provide a phone number for your doctor to contact Moda staff regarding the prescription.  If this is an emergency situation, call Moda Health at 1-800-913-4311, or the Trust Office for assistance. 

Discussing your prescription(s) and the prescription care management programs under the Plan with your physician at the time you are given a new prescription should eliminate any delay in getting your prescription(s) filled at the pharmacy. 

If you have any questions or would like additional information on the certain, specific medications that may come under the prescription care management programs, please call Moda Health at 1-800-913-4311 or visit their website at www.Modacompanies.com.