Friday, February 6, 2026

Frequently Asked Health Care Questions


Q. My child is going to college in a location outside of our service territory (i.e., New Mexico, Texas, etc.) How will his/her claims be paid, as in-network or out-of-network?
A. The claim will be considered out of area and reimbursed at the in-network reimbursement level.
Q. Is vision therapy covered under the Plan?
A. Vision therapy is not a covered benefit under the Plan.
Q. How are R&C (reasonable & customary) charges determined? Is it specific to zip code? If there is only one hospital in the area, how is R&C determined?
A. R&C does not apply to hospital fees. The Plan pays the semi-private room rate. If rooms are billed as private, the Plan will apply the semi-private room rate for that facility and you will be responsible for the difference in cost. The Plan utilize the MDR schedule at the 90th percentile for physician, lab, X-ray, etc. expenses.
Q. Can employees receive a copy of the R&C schedule of benefits for every procedure?
A. A printed copy of the R&C schedule cannot be sent to every employee. However, you may contact BeneSys Administrators with your provider’s zip code, procedure code and the amount that will be billed and BeneSys Administrators can tell you if the charge is within the allowable fee or if it’s over R&C.
Q. If an employee and spouse are both covered by the Plan as employees, how does coordination of benefits work?
A. When an employee and spouse are both covered under the Plan, internal coordination of benefits is done. No paperwork is required by the member or provider(s). The Plan pays as primary carrier on the employee and secondary carrier under the spouse. Example: Employee enrolled under the Consumer Driven Health Plan(CDHP) with a spouse who is enrolled with employee and spouse coverage under the Premium Health Plan. If the employee, insured, who is enrolled in the Consumer Driven Health Plan(CDHP) incurs $1,000 in eligible emergency room expenses at an in-network hospital, the PPO discount would be taken on the bill and the balance applied towards the Consumer Driven Health Plan(CDHP) deductible of $2,600. The claim would then be processed under the spouse’s Premium Health Plan as a dependent. The PPO discount would be taken on the $1,000 emergency room expenses, a $100 co-payment would be applied, and the balance would be reimbursed at 90% of eligible expenses. Primary coverage for eligible dependent children is determined by the birthday rule. The parent whose birthday falls earliest in the calendar year (month and day) is the primary carrier. The parent whose birthday falls later in the year (month and day) is the secondary carrier.
Q. What will happen if the call for precertification is not made 7 days in advance? Will all services be denied?
A. A $200.00 penalty will be assessed if medically necessary services are not precertified. Claims for medical services or supplies that have not been precertified may be subject to retrospective review to determine if they are medically necessary. If the services or supplies are determined to not be medically necessary, no benefits will be provided by the Plan.
Q. If an individual is seeking assistance for fertility and a physician discovers endometriosis, which can be a severe medical problem, will the Plan cover this treatment since many types of infertility problems are health-related problems for a female?
A. If the diagnosis is endometriosis, treatment for this condition would be eligible under the Plan. Any charges for infertility would be excluded per the Plan document.
Q. What are the Plan benefits for speech therapy?
A. Speech therapy is a benefit if the loss was due to an injury or illness. Speech therapy is not a covered benefit if services are not to restore a loss.