Section 9: > Index
Index
A
Accidental Death and Dismemberment (AD&D) Plan, 80-81
| |
eligibility, 4
benefits, 80-81
converting coverage, 81
requesting benefits, 81 |
Active participants, 6-7, 38-40
| |
coordination of benefits, 38-40
eligibility, 6-7 |
Acupuncture/acupressure, 59
Administrative information, 82-92
| |
claims and appeals rules, 86-90
ERISA rights, 85-86
general plan information, 82-84
HIPAA rights, 90
overpayments, 91
plan termination, 92
reimbursement and subrogation, 90-91 |
Air bag benefit, 81
Alternative therapies, 53
Ambulance transfers, 55
Assignment of benefits, 37
C
Case management, 37
Certified Retirees, 6, 12-13
| |
coordination of benefits, 41
dependent coverage premiums, 12
eligibility, 12
Medicare Part B, 13 |
Children
| |
court orders and children's coverage, 39,
78
coverage by more than one plan, 39
dependent, 6-7, 16
full-time students, 16
of same-sex partners, 7 |
Claim-filing process
Claims and appeals, 86-90
| |
denial notices, 87
denied claims, 87-88
disability claims, 89
filing claims, 86
initial claim determinations, 86-87
other claims, 89 |
COBRA continuation coverage, 17-20
| |
coordination with Medicare, 41
coverage options, 19
eligibility, 17
end of coverage, 20
Low Option Plan, 33-35
qualifying events, 18 |
Coinsurance, 24, 64
Contact information, Summary Of Benefits
Contact lenses or eyeglasses, 53
Coordination of Benefits (COB), 38-41
| |
active participants, 38-40
Certified Retirees, 41
COBRA participants, 41 |
Copayments, 24, 71
Court orders and children's coverage, 39, 78
D
Deductibles, dental, 63
Deductibles, medical, 23-24
DeltaCare Dental HMO (DHMO), 71-77
| |
copays, 71
dental providers, 72
emergency care, 73
expenses, eligible, 74-76. See also Expenses,
eligible DHMO
expenses, ineligible, 76-77
filing claims, 77
network vs. non-network, 73
plan limitations, 75-76
Primary Care Dentist (PCD), 72 |
Delta Preferred Option (DPO), 62-70
| |
alternative benefit provision, 67
annual benefit maximum, 64
coinsurance, 64
coordination of benefits, 38-41
deductible, 63
dental providers, 65
emergency care, 64
expenses, eligible, 67-69. See also Expenses,
eligible DPO
expenses, ineligible, 69-70
filing claims, 70
plan limitations, 68-69
predetermination of benefits, 67
reasonable and customary limits, 64 |
Dependent coverage premium, 9
Dependents
| |
adding, 10
changes in status, 9
definition of, 6-7
dependent coverage premium, 6-7, 9
enrollment of, 8 |
Disability
| |
benefits, 79
claims, 89
extension of coverage, 19 |
Domestic partners, same-sex, 6-7
Drugs. See Prescription drugs; Mental Health and
Substance Abuse
Durable medical equipment, 56
E
Earnings and coverage eligibility, 4-5
Eligibility, 4-7
| |
active participants, 6
Certified Retirees, 6
dependent children, 6-7, 16
eligible dependents, 6-7, 16
granted in error, 6
loss of, 13
same-sex domestic partners, 6-7
spouses, 6 |
Eligible dependents, 6-7, 16
Emergency dental care, 64, 73
Emergency medical care, 36
Emergency prescription refills, 43 sidebar
Employee Retirement Income Security Act of 1974
(ERISA), 85
Employer contributions, 6
End of coverage, 8, 92
Enrollment for benefits, 8
Expenses, eligible DHMO, 74-76
| |
bridges, 74
crowns, 74
dentures, 74
diagnostic, 74
endodontic, 75
general services, 75
oral surgery, 74
orthodontic, 75
periodontic, 74
preventive, 74
restorative, 74 |
Expenses, eligible DPO, 67-69
| |
basic, 67
cast restoration, 68
crowns, 68
diagnostic, 68
implants, 68
inlays, 68
jackets, 68
onlays, 68
orthodontic, 68
preventive, 68
prosthodontic, 68 |
Expenses, eligible medical, 23, 53-58
| |
acupuncture/acupressure, 59
alternative medical benefit, 53
ambulance transfers, 55
contact lenses or eyeglasses, 53
durable medical equipment, 56
elective surgery, 53
electro convulsive therapy (ECT), 53
enhanced external counterpulsation therapy
(EECT), 54
home health care, 54
home infusion therapy, 54
hospice care, 54
hospital, surgical, medical, 55-56
inversion device, 56
mastectomy benefit, 56
mental health and substance abuse, 56
physical and occupational therapy, 53,
54, 55
skilled nursing facility, 57
speech therapy, 57-58
temporomandibular joint dysfunction (TMJ), 58
transplants, organ and tissue, 56-57
wellness benefit, 59
wigs, 59 |
Expenses, ineligible DHMO, 76-77
Expenses, ineligible DPO, 69-70
Expenses, ineligible medical, 59-61
Explanation of Benefit (EOB) form, 39 sidebar
Extended Coverage Program, 14-15
| |
for individual writers, 15
for two-person teams, 15
Low Option Plan, 33-35 |
Extensions of coverage, 13-20
| |
active survivor coverage, 16
Certified Retiree survivor coverage, 17
full-time students, 16
total disability, 16 |
Eyeglasses or contact lenses, 53
F
Foreign country, treatment in, 37 sidebar
Frequently asked questions, 93-94
G
General plan information, 82-84
| |
administrator, 82
trustees, 84 |
Generic drugs, 42-43
Glossary, 97-104
H
Health Insurance Portability and Accountability Act (HIPAA), 90
Home infusion care, 36 sidebar, 54
Hospice care, 54
Hospital
I
Inversion device, 56
L
Life Insurance Plan, 79-80
| |
benefits, 79,
80
converting coverage, 80
eligibility, 4
if you become disabled, 79
if you retire, 79
requesting benefits, 80 |
Lifetime maximum benefit, 25-26
Low Option Plan, 33-35
| |
coordination of benefits, 38
denied claims, 87
emergency care, 36
expenses, eligible, 53-58. See also Expenses,
eligible medical
expenses, ineligible, 59-61
filing claims, 37
provider directory, 33
urgent care, 35 |
M
Mail-order service, 44-45
Mastectomy benefit, 56
Medical emergency, 36
Medicare, 13
| |
assignment, 41
sidebar
coordination with COBRA, 41
Part B, 13 |
Mental Health and Substance Abuse, 48-51,
56
PBH network vs. non-PBH network, 48-50
precertification, 51
Serious Mental Illness (SMI), 49
N
Newborns' and Mothers' Health Protection Act (federal law), 78
O
Oral surgery, 74
Organ and tissue transplants, 56-57
Orthodontic care, 64, 68,
75, 76
Out-of-pocket maximum, 25
Overpayments, 91
P
PacifiCare Behavioral Health (PBH) network, 48-51
Periodontic benefits, 74
Pharmacies, 43
Physical and occupational therapy, 53, 54,
55
Pre-existing condition, 7
Pregnancy, complications of, 98
Prescription drugs, 42-48
| |
cost, 45
Dispense as Written (DAW), 43
eligibility, 42
expenses, covered, 46
expenses, not covered, 46-47
filing claims, 48
generic, 42-43
mail-order service, 44-45
non-preferred brand, 42
preferred brand, 42
refills, 43 sidebar, 45
retail purchase, 43-44 |
Primary Care Dentist (PCD), 72-73
Prosthodontics, 63, 68
Q
Qualified Medical Child Support Orders (QMCSOs), 78
Qualifying events, COBRA, 18
R
Reasonable and customary (R&C) limits
| |
dental (DPO), 64
medical, 25 |
Regular Plan, 26-29
| |
coordination of benefits, 38
coverage for non-network providers at network facilities, 35
denied claims, 87
emergency care, 36
expenses, eligible, 53-58. See also Expenses,
eligible medical
expenses, ineligible, 59-61
filing claims, 37
network vs. non-network, 26-28
provider directory, 26 sidebar
urgent care, 36 |
Reimbursement and subrogation, 90-91
Retail prescriptions, 43-44
Retirees, Certified, 12-13
| |
coordination of benefits, 41
dependent coverage premiums, 12
eligibility, 12
Medicare Part B, 13 |
S
Same-sex domestic partners, 6-7
Seat belt benefit, 81
Serious Mental Illness (SMI), 49
Skilled nursing facilities (SNF), 57
Speech therapy, 57-58
Students, full-time, 10, 16
Substance abuse. See Mental Health and Substance Abuse
Summary Of Benefits, back pocket
Surgical benefits, 53, 55-56
T
Termination of coverage, 8 sidebar, 92
The Industry Health Network (TIHN), 32
Therapy
| |
alternative therapies, 53
covered providers, 53 sidebar
electro convulsive (ECT), 53
enhanced external counterpulsation (EECP), 54
home infusion care, 54
speech therapy, 57-58 |
Transplants, organ and tissue, 57-58
Trustees of health plans, 84
U
Urgent care, 36
V
Vision benefits, 51-52
| |
cost, 52
eligibility, 52
expenses, covered, 52
expenses, not covered, 52
filing claims, 37 |
W
Wellness benefit, 58
Wigs, 58
Writer's Point System, 14-15
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