Transcription
Public Education Employees’ Health Insurance Plan (PEEHIP)Office LocationMailing AddressPhone Numbers201 South Union StreetP. O. Box 302150877.517.0020 or 334.517.7000Montgomery, AL 36104-0001Montgomery, AL 36130-2150Fax: 877.517.0021 or 334.517.7001www.rsa-al.govFlexible Spending Accounts877.517.0020 or s Program, Weight Watchers, & ALL Kids (Administered by the Department of Public Health)RSA Tower, Suite 900Tobacco Cessation QuitlineALL KidsP.O. Box 303170800.QUIT.NOWP.O. Box 304839Montgomery, AL 36130-3017800.784.8669Montgomery, AL 36130-4839www.adph.org888.373.5437Phone Numberswww.adph.org/allkids334.206.5300 or 800.252.1818Blue Cross Blue Shield of Alabama - Administrator of Hospital/Medical, Flexible Spending Accounts, & Supplemental Plans450 Riverchase Parkway East Customer ServicePreadmission CertificationFlexible BenefitsP.O. Box org/peehip1/Birmingham, AL 35298www.bcbsal.org/peehip1/Rapid Response to order ID cards, directories & claim forms800.248.5123Baby YourselfFraud Hot Line800.222.4379800.824.4391MedImpact - Administrator of Core Pharmacy10680 Treena StCustomer ServicePharmacy Help DeskSan Diego, CA 92131(Available 24 hours/day) (Available 24 hours/day) (For Physician 8.2949Step Therapy Prior Authorization800.347.5841Fax: 877.606.0728Bioscrip Specialty Pharmacy - Administrator of Specialty Pharmacy2791 Charter StCustomer ServiceColumbus, OH 43228877.694.5320www.bioscrippeehip.comFax: 877.212.8388 (For Physician Use)VIVA Health Plan1222 14th Avenue South205.558.7474Delta Dental Customer ServiceBirmingham, AL 35205800.294.7780(Dental provider for Viva Health d Benefit Solutions - Administrator of Cancer, Dental, Indemnity, & Vision Optional Plans1812 University Blvd.800.476.0677P.O. Box 1250www.southlandnationalpeehip.comTuscaloosa, AL 35403
PEEHIP Member HandbookIntroductionThe Retirement Systems of Alabama (RSA) is pleased to provide you with the2011-2012 Public Education Employees’ Health Insurance Plan (PEEHIP)Member Handbook. This handbook is an important part of our commitmentto provide our members with valuable information about their health care benefits.Please read this handbook thoroughly and keep it with your other benefit materials.Your member handbook is a very useful tool when you have questions about yourPEEHIP benefits. It will help you make informed decisions about your future.Important!Due to the Federal Health Care Reform Legislation that passed in 2010, additional changes mayoccur to the PEEHIP program. For the most up to date information, please refer to the latestPEEHIP Member Handbook on the Web site at www.rsa-al.gov/PEEHIP/peehip.html.The information in this handbook is based on the Code of Alabama 1975, Title 16, Chapter25A. This handbook is not intended as a substitute for the laws of Alabama governingPEEHIP nor will its interpretation prevail should a conflict arise between its contents andChapter 25A. Furthermore, the laws summarized here are subject to change by the AlabamaLegislature. Do not rely solely upon the information provided in this handbook to make anydecision regarding your health care benefits, but contact PEEHIP with any questions youmay have about your health care benefits.
ContentsContentsInsurance Eligibility 1Enrollment Issues 6Plan Summaries and Benefits 12Federal Poverty Level Assistance Program (FPL) 26Premium Rates 27Comparison of Benefits 33Updating Information 36Allocations 37Surviving Dependent Benefits 42Provision for Medicare-Eligible Members 43Health Insurance Policies for Retired Members 45Important Notice About Your Prescription Drug Coverage and Medicare 48COBRA 50Leave of Absence & Family and Medical Leave Act 53Health Insurance Portability and Accountability Act (HIPAA) 54Notice to Enrollees in a Self-Funded Non-Federal Governmental Group Health Plan 58Medicaid and CHIP Offer Free or Low-Cost Health Coverage to Children and Families 59Member Online Services – It’s Fast, FREE, Secure and Accurate! 61Forms 63
Guidelines for InsuranceEligibility for Active MembersFull-time employees and permanent part-timeemployees are eligible for coverage with PEEHIP.Full-time EmployeesA full-time employee is any person employedon a full-time basis in any public institution ofeducation within the state of Alabama. Theseinstitutions must provide instruction for anycombination of grades K through 14 exclusively,under the auspices of the State Board ofEducation.Permanent Part-time EmployeesAn eligible permanent part-time employeeis not a substitute or a transient employee. Apermanent part-time employee is eligible forPEEHIP if he or she agrees to payroll deductionfor a pro rata portion of the premium cost fora full-time employee. The portion is based onthe percentage of time the permanent part-timeworker is employed.Ineligible EmployeesThe following employees are not eligible toparticipate in PEEHIP: A seasonal, transient, intermittent oradjunct employee who is hired on anoccasional or as needed basis. An adjunct instructor who is hired ona quarter-to-quarter or semester-tosemester basis and/or only teaches when agiven class is in demand. Board attorneys and local school boardmembers if they are not permanentemployees of the institution. Contracted employees who may be on thepayroll but are not actively employed by theschool system. Extended day workers hired on an hourly oras needed basis.Family Coverage EligibilityMembers can enroll their eligible dependentsunder PEEHIP by: 1) enrolling online atwww.rsa-al.gov; or 2) filing a HealthInsurance and OptionalApplication with PEEHIP.EnrollmentAn eligible dependent is defined as:1. The employee’s spouse as defined byAlabama law to whom you are currentlyand legally married. (Excludes a divorcedand common law spouse.)PEEHIP provides eligibility for a spouseto whom a member is currently and legallymarried and requires a copy of a marriagecertificate to verify eligibility and oneadditional current document to show proofof current marital status such as one of thefollowing:Option #1 Marriage certificate AND one of the following tax documentsto show marriage is still current: Page 1 and signature page ofmember’s most current FederalIncome Tax Return (1040, 1040A or1040EZ) as filed with the IRS listingthe spouse Page 1 and Certificate of ElectronicFilingortransmissionpage(if electronically completed orcompleted by a tax professional)of member’s most current FederalIncome Tax Return (1040, 1040A,or 1040EZ) as filed with the IRSlisting the spouse Transcript of member’s most currentFederal Income Tax Return (1040,1040A, or 1040EZ) listing the spouseOption #2 Marriage certificate AND one of the following documents toshow marriage is still current: Current mortgage statement, homeequity loan, or lease agreementlisting both member and spouse Current property tax documentslisting both member and spouse Automobile registration that iscurrently in effect listing bothwww.rsa-al.gov1Insurance EligibilityInsurance Eligibility
Insurance Eligibility member and spouseCurrent credit card or accountstatement listing both member andspouseCurrent utility bill listing bothmember and spouseCurrent utility bill listing the spouseat the same address as the memberNote: “Current” is defined as within the last six months.2. In accordance with the federal Health CareReform Legislation, the following adultchildren are eligible for coverage underyour contract:a. A married or unmarried child underthe age of 26 if the child is yourbiological child, legally adopted child,stepchild or foster child withoutconditions of residency, student status,or dependency. A foster child is anychild placed with you by an authorizedplacement agency or by judgment,decree, or other order of any court ofcompetent jurisdiction.b. The eligibility requirements for anyother children such as grandchildren,for example, must meet the samerequirements as foster children andmust be placed with you by decree orother order of any court of competentjurisdiction, for example, legal custodyor legal guardianship.However, PEEHIP is not requiredand will not provide coverage for achild of a child receiving dependentcoverage. Also, maternity benefitsare not covered for children of any ageregardless of marital status.3. A dependent child of any age incapable ofself-sustaining employment because of aphysical or mental handicap and is chieflydependent on the employee for support.The handicap must have existed prior tothe time the child attained age 26. Also,the child had to be covered as a dependenton the employee’s PEEHIP policy beforereaching the limiting age. For example,2877.517.0020approved incapacitated children cancontinue on any PEEHIP plans they are onat the time they age out, but they are noteligible to be covered on other PEEHIPplans once they reach the limiting age of 26.The employee must contact the PEEHIPoffice and request an IncapacitatedDependent form.Proof of the child’scondition and dependence must besubmitted to PEEHIP within 45 days afterthe date the child would otherwise cease tobe covered because of age. PEEHIP mayrequire proof of the continuation of suchcondition and dependence. If the childis approved as an incapacitated child andallowed to stay on the PEEHIP HospitalMedical Plan, the child cannot change plansand be covered on other PEEHIP plans,such as an HMO or Optional Plan if he orshe has already reached the limiting age of26.Adult ChildrenPEEHIP is required to offer and extenddependent hospital medical coverage (at themember’s option) to adult children up to age 26.The normal family hospital medical rate will becharged to anyone who enrolls an eligible adultchild between the age of 19-26. No additionalcharge will be required. Members will beallowed to enroll their adult child(ren) duringthe annual Open Enrollment period whichbegins July 1 and ends August 31 for an October 1effective date. Maternity benefits are not coveredfor children of any age regardless of maritalstatus.Documentation Required by PEEHIPEvery member who has a dependent enrolled onhis or her PEEHIP coverage(s) will be requiredto certify to PEEHIP their dependent’s eligibility.Certification may require appropriate documentsto support your dependent’s eligibility. Suchdocuments required will be a marriage certificateand one additional document to show proof ofcurrent marital status for a spouse such as one ofthe following:
Option #2 Marriage certificate AND one of the following documents toshow marriage is still current: Current mortgage statement, homeequity loan, or lease agreementlisting both member and spouse Current property tax documentslisting both member and spouse Automobile registration that iscurrently in effect listing bothmember and spouse Current credit card or accountstatement listing both member andspouse Current utility bill listing bothmember and spouse Current utility bill listing the spouseat the same address as the memberNote: “Current” is defined as within the last six months.Other documents required are a birth certificatefor a natural child; a certificate of adoption foran adopted child; a marriage certificate and abirth certificate for a step child; a placementauthorization for a foster child; a court ordersigned by a judge appointing legal guardianshipor legal custody for other children who are notbiological, adopted or step children.Enrollments cannot be processed withoutthe appropriate documentation as explainedabove.PEEHIP is not bound by a court order toinsure dependents who do not meet PEEHIPguidelines.Dependent Eligibility AuditPEEHIP has limited funds to cover the high costof claims and coverage of its eligible membersand their dependents who are enrolled inPEEHIP coverages. PEEHIP must use its limitedfunds appropriately and this entails monitoringcompliance with eligibility policies to preventfraud, waste and abuse. Therefore, PEEHIPis conducting a dependent eligibility audit toensure compliance with its dependent eligibilitypolicies.If you are covering an ineligible dependent, youmust notify PEEHIP and disenroll the dependentimmediately. If you know of someone who iscovering an ineligible dependent, please notifyPEEHIP by phone 877.517.0020, fax 877.517.0021,email peehipinfo@rsa-al.gov or mail PEEHIP,P.O. Box 302150, Montgomery, AL 36130-2150.Covering ineligible dependents unnecessarilyraises costs for all eligible PEEHIP members.Help PEEHIP prevent fraud, waste and abusethrough compliance with its dependent eligibilitypolicies.Ineligible Dependents Once an “eligible” dependent has “agedout,” that person is ineligible to participatein PEEHIP again as a dependent exceptsubsequently as the spouse of an eligiblemember. The ineligible dependent must beremoved from coverage the first day of themonth following his or her 26th birthday. Ex-spouses and ex-stepchildren are noteligible dependents even if a membercontinues to pay for family coverage. Theex-spouse and ex-stepchildren must bedeleted from coverage effective the first dayof the month following the date of divorce.The member will be responsible for an exspouse’s and ex-stepchildren’s claims whenthey are not removed from coverage.www.rsa-al.gov3Insurance EligibilityOption #1 Marriage certificate AND one of the following tax documentsto show marriage is still current: Page 1 and signature page ofmember’s most current FederalIncome Tax Return (1040, 1040A or1040EZ) as filed with the IRS listingthe spouse Page 1 and Certificate of ElectronicFilingortransmissionpage(if electronically completed orcompleted by a tax professional)of member’s most current FederalIncome Tax Return (1040, 1040A,or 1040EZ) as filed with the IRSlisting the spouse Transcript of member’s most currentFederal Income Tax Return (1040,1040A, or 1040EZ) listing the spouse
Insurance Eligibility An employee who is eligible for PEEHIPas a subscriber cannot be covered as adependent child on another PEEHIPpolicy. A child of a dependent child cannot both becovered on the same policy. Examples of ineligible dependents include,but are not limited to, the following:ex-spouse; daughter-in-law or son-inlaw; grandchildren or other childrenrelated to you by blood or marriage otherthan biological, adopted, foster or stepchildren for which you do not have legalguardianship or legal custody; childrennot related by blood or marriage to you forwhich you do not have legal guardianshipor legal custody who are not foster childrenor adopted children.COBRA for Dependents When a child or spouse is no longer eligiblefor coverage, he or she may be eligibleto continue health insurance coverageunder COBRA. To elect coverage underCOBRA, the member or dependent mustnotify PEEHIP within 60 days from thedate the dependent is no longer eligible forcoverage.Newly Acquired Dependents and Single CoverageMarriageA member enrolled in single coverage whomarries and wishes to acquire family coveragecan request coverage within 45 days of themarriage. You must mail a copy of the marriagecertificate to PEEHIP after adding the newspouse to coverage through Member OnlineServices at www.rsa-al.gov. The effective dateof coverage can be the date of marriage or thefirst day of the following month. The 270-daywaiting period on pre-existing conditions iswaived if proof of previous coverage is receivedand approved by PEEHIP. Prior notification isnot required.If you do not enroll your new spouse through theonline system or in writing within 45 days of thedate of marriage, the policy cannot be changed tofamily and the new spouse cannot be added untilthe Open Enrollment Period. This policy applies4877.517.0020to active members only because the premiums foractive members are pretaxed and IRS guidelinesdo not allow coverage changes outside of the 45days from the qualifying event.NewbornMembers enrolled in single coverage who desirefamily coverage due to the birth of a child canrequest coverage within 45 days of the birth. Youmust provide a copy of the birth certificate andthe child’s Social Security number after addingyour newborn through the Member OnlineServices system at www.rsa-al.gov. You can alsosubmit written notification to PEEHIP within45 days of the date of birth. The effective date ofcoverage can be the date of birth or the first dayof the following month. A waiting period on preexisting conditions is waived for the newbornchild. Prior notification is not required.If PEEHIP does not receive your onlineenrollment or written notification within 45days of the date of birth, the policy cannot bechanged to family and the new dependent cannotbe added until the Open Enrollment period. Thispolicy applies to active members only becausethe premiums for active members are pretaxedand IRS guidelines do not allow coverage changesoutside of the 45 days from the qualifying event.If a newborn is not covered on the date of birth,claims for the newborn at the time of birth willnot be paid.When adding family coverage, a member can addall eligible dependents to the policy. However, thenewly added dependents who are age 19 or oldermay be subject to the 270-day waiting period onpre-existing conditions unless proof of previouscoverage is received and approved by PEEHIP. Amember who is only enrolled in the four OptionalPlans cannot enroll in the Hospital Medical Plandue to the birth of a child.Newly Acquired Dependents and Family CoverageIf a member is enrolled in family coverage, themember may enroll a new dependent(s) by usingthe Member Online System at www.rsa-al.gov orby completing and mailing a Health Insuranceand Optional Status Chan
under PEEHIP by: 1) enrolling online at www.rsa-al.gov; or 2) filing a Health Insurance and Optional Enrollment Application with PEEHIP. An eligible dependent is defined as: 1. The employee’s spouse as defined by Alabama law to whom you are currently and lega
