Guide to Your Benefits and Enrollment

Transcription

1 Guide to Your Beefits ad Erollmet Arizoa School Boards Associatio Isurace Trust

2 Fid Balace Betwee a Good Life ad Good Health Joi us! Are you ready to commit to a health pla that ca help restore balace to your life? It s simple to eroll just follow these four steps. Ad if you have ay questios durig the erollmet process, check with your beefits admiistrator. Oce you ve completed Step 4 ad you ve served ay waitig period, you re o your way to a fresh ew approach to livig your best health. Step 1: Gather your iformatio. For a complete, efficiet erollmet, you may eed some of the iformatio below. Spouse s ad childre s birth dates. Spouse s ad childre s Social Security Numbers (SSN). Date of marriage. If your spouse or childre are covered uder aother health pla, the ame of the pla or isurace carrier ad the effective date of beefits. If your beefits will iclude life isurace, your beeficiaries ames ad SSNs. Step 2: Double-check every form. The decisios you make as you eroll i your health pla will affect your future healthcare ad fiaces. We wat to help you choose wisely. Take the time to carefully read through this packet. Do t eroll without uderstadig your optios. Cosider: Your persoal health ad the health of your family members. Healthcare expeses you ca predict for you ad your family. Other health beefits you or your family members may have. Your budget for beefits ad expected healthcare services. Remember: Copays ad deductibles are out-of-pocket costs you will pay for doctor visits ad other medical services. If you or ay depedet(s) are covered by aother health pla, you have several optios. If you declie beefits ow, you wo t be able to eroll later uless a special erollmet situatio occurs, or durig a ope erollmet period. Step 3: Make your decisio. It s time to make chages i the way you thik about your health ad your healthcare. It s time to step up, take charge ad make the best use of your pla, your moey ad your time. Are you ready to commit to better health, a better life ad the balace you wat? We are ready ad committed to helpig you. I this sectio: Gatherig iformatio Double checkig your iformatio Makig your decisio Completig erollmet Waitig period. Please refer to your district Huma Resources departmet for iformatio about your pla s waitig period. Step 4: Complete your erollmet. 1

3 Beefit Highlights Uderstadig your beefits. Your prevetive care beefits: Coverage for prevetive care as required by healthcare reform. Additioal welless beefit for tests ad procedures ot covered uder healthcare reform. Healthcare beefits whe you re sick: I-etwork vs. out-of-etwork Ipatiet vs. outpatiet care Doctor visits ad prescriptio drugs Mail order prescriptios Programs for healthy chage: Workig~Well Employee Welless Program: Programs to help you improve your health, fitess ad quality of life. Catamara cliical programs: Step care, diabetes maagemet, medicatio moitorig ad specialty pharmacy. Discouts offered to you for weight maagemet, eye care, Lasik ad a variety of products ad services. Improve your overall health with ASBAIT detal ad visio beefits (if applicable): Freedom to utilize ay provider of your choice. Beefits payable to ay provider Direct member reimbursemet available. For a listig of your detal ad visio beefits, refer to the Beefits Schedule. Refer to your SPD for more complete iformatio. Support whe you eed it: Employee Assistace Program (EAP) brought to you by Alliace Work Parters. EAP Nurse Lie: Talk to a registered urse aytime, 24/7, about questios ad symptoms. Access easy-to-use decisio support tools that help you weigh your care optios, ad provide cost ad quality iformatio. 2

4 No Surprises, Just Iformatio How healthcare reform affects your pla: I March 2010, Presidet Obama siged the Patiet Protectio ad Affordable Care Act, or PPACA, ito law. PPACA, also kow as health care reform icludes certai cosumer protectios that apply to the ASBAIT Health Pla, for example, the requiremet for the provisio of prevetive health services without ay cost sharig. Be sure to review the importat iformatio about PPACA that is icluded throughout this kit. Importat thigs to kow about eligibility. Health plas are put together carefully to provide the best beefits possible for participats. We kow how importat it is for healthcare cosumers like you to really uderstad how your pla works. I this way, you ca make the chages you wat i your health ad i your life. The ext sectio of this packet describes some of the most importat provisios of your beefits. It s aother way we re workig with you to help you get the most from your beefits so you ca live a life that s balaced ad iformed, with o surprises. Healthy balace for your family, too. Your family members ca reap the rewards of the pla, too. Healthcare beefits are available for every eligible depedet. It s a great way to help your family members fid the right balace betwee life s roller-coaster ride ad their best health. Be sure your family kows about the opportuities ope to them share this packet ad other materials you receive from the pla! Your eligible depedets. The ASBAIT Pla is ope to you ad your eligible depedets. A eligible depedet is: Your spouse (as defied i your pla documets). Your childre, atural or adopted. Stepchildre. Childre who have bee placed with you for adoptio. Childre for whom you are the legal guardia. Importat ote: Depedet coverage is ow available for ay child (regardless of marital status, residecy, studet status, etc.) of a employee who is deemed to be the employee s biological, step, foster or adopted child (icludig a child placed for adoptio) util such child reaches age 26 (please ote: this coverage will NOT apply to ASBAIT detal ad visio beefits). Please refer to your summary pla descriptio for specific requiremets. Whe your depedets are ot eligible for beefits uder your pla. Tell your employer if: You become divorced or are legally separated from a spouse who was covered uder this pla. A depedet child ceases to meet the terms of the pla. I this sectio: Health beefits for your family Erollig at a later date Special erollmet situatios If your spouse already has coverage Pre-existig coditio limitatios Creditable coverage Whe you have beefits from two group plas. If you or oe of your depedets have beefits uder both this pla ad aother pla, the two plas will coordiate your beefits. Oe pla will be cosidered the primary pla (or first payer) ad the other will be the secodary pla (pays oly after the first pla has paid). Geerally, we use a birthday rule to decide which of the two plas would be the primary pla. The birthday rule. If both parets provide beefits for a child, the the primary pla is the oe from the paret whose birthday comes first i the year. So, if oe paret s birthday is Jauary 12 ad the other paret s is April 1, the primary payer will be the pla from the paret whose birthday comes first Jauary 12. I the uusual case that both parets have the same birthday, the pla of the paret who has provided beefits logest for the child will be primary. 3

5 To eroll the depedet for COBRA a special limited-time pla for cotiuig beefits at your ow expese you must otify your employer withi 60 days of that perso s chage i depedet status. If you say o to this pla ow. You ca refuse the beefits of this pla, but be sure you ve looked at the pluses ad miuses of that decisio. Importat: If you do t eroll ow, you ll have to wait for your employer to offer a ope erollmet period. If you lose other group beefits that you or your depedets might have, ad it s ot your fault (for example, the covered perso is laid off or let go from a job) you ll be able to sig up for this pla. Likewise, if you have a evet such as your ow marriage, divorce, or the birth or adoptio of a child, you will have aother brief period to sig up for this pla without waitig for your employer s ope erollmet period. These are cosidered Qualifyig Evets. Pre-existig coditio limitatio. If you ve had treatmet for a health coditio, or if treatmet for a coditio has bee recommeded but ot received, withi the six moths before your erollmet i this pla, that coditio may be cosidered pre-existig ad wo t be covered by this pla for up to 12 moths. If you eroll late, the coditio may ot be covered for 18 moths. However, if a perso has had other creditable healthcare beefits withi 63 days of erollig for this pla, that coverage time will be subtracted from the pre-existig coditio limitatio period. Waitig periods do ot cout as creditable coverage. To reduce your pre-existig coditio limitatio period uder this pla, cotact your previous employer to get a Certificate of Creditable Coverage showig how log you were covered uder that employer s health pla. Keep a copy for yourself ad give oe to your employer. If you have questios, or ay problems gettig the Certificate, talk to your employer. Please ote that pregacy is ever cosidered a pre-existig coditio. Please ote: Covered idividuals uder age 19 are ot subject to pre-existig limitatios. Creditable coverage. If you have had other health pla beefits recetly, it may be applied to shorte the pre-existig coditio limitatio of the pla. A pre-existig coditio is a health coditio for which you received treatmet withi a stated period of time as defied by your pla. Importat ote: If withi the 63 days before this pla becomes effective, ay pla participat age 19 ad over who were covered by aother healthcare pla (creditable coverage), the time erolled i the previous pla is subtracted from the legth of ay pre-existig coditio limitatio, shorteig it or elimiatig it altogether. A creditable health pla meas: Aother employer-sposored group pla COBRA cotiuatio coverage A HMO Idividual healthcare isurace Medicaid ad/or Medicare A public health pla Peace Corp pla State Childres Health Isurace Program Plas that are t cosidered creditable are: Log-term care beefits Disability icome isurace Auto medical paymet isurace If you have a family member covered by a differet pla: Ope erollmet period. If you waive or declie beefits at first but chage your mid later, you ca sig up durig the time period desigated by your employer as ope erollmet. Special erollmet situatios. I these situatios, you may be able to add, delete or chage your beefit choices. You ca eroll yourself ad your eligible depedets i this pla. You ca eroll yourself i this pla, but declie beefits for some or all depedet(s). You ca declie beefits for your whole family. Ivolutary loss of other beefits Marriage Birth Adoptio Placemet of a child i your home for adoptio If you re addig a depedet to your beefits through a special erollmet situatio, let your employer kow withi 30 days of the marriage, birth, adoptio, etc.; however, this ca vary by group. 4

6 Balacig Your Life Meas Protectig Your Health Uderstadig your Medical Beefits. Chaces are, you try every day to restore a healthy balace to your life, but time gets away from you, or other details come first. ASBAIT is here to help you focus, to support you every step of the way. Read about your beefits i the ext sectios, ad lear all you ca about usig your pla to make healthy chages. Thik of the beefits ad programs as a importat resource i the protectio of your body, mid ad spirit! Prevetive care for you ad your family: Protectig your healthy balace. Questio: Which is better: Takig a hour or two out of your busy day to have your aual checkup or missig hidde symptoms ad payig the price i sick days, copays ad missed evets? Aswer: Nothig makes more sese i these busy times tha prevetig illess before it happes. That s why your pla offers excellet beefits for prevetive services. Prevetive Care: I-Network Physical exams 100% Well-Child Care 100% Mammogram 100% Pap smears 100% Prostate blood test 100% Screeig lab work 100% Chages to prevetive care beefits. Your prevetive care beefits have bee ehaced to provide you ad your family with a eve greater opportuity to take commad of your health ad well beig. Prevetive care beefits covered i-etwork at 100%. As required by PPACA, ad listed o the U.S. Prevetive Task Force list, certai prevetive beefits are covered at 100%, with o cost to you. For a complete listig, visit Additioal Welless Beefit: I-Network Welless tests ad procedures ot covered uder PPACA: First $300 covered at 100%, 10% of eligible thereafter Prevetive care at o cost to you. I-etwork prevetive care beefits covered at 100% iclude, but are ot limited to: Aual exams ad check-ups. Well-child care. Immuizatios ad screeigs. For a complete listig, visit 5

7 Coverage of Wome s Prevetive Services Good ews for wome! Your beefits pla covers the wome s prevetive services 1 listed below, with o copays, coisurace or deductible whe provided i-etwork. You wo t have to pay aythig for these services whe: The doctor or other healthcare provider is i your etwork ad the mai purpose of your visit is to get prevetive care. You choose geeric cotraceptives. 2 You buy a breast pump accordig to the guidelies of your beefits pla. Please ote, wome s prevetive care is ot cosidered prevetive whe it is part of a visit to diagose, moitor or treat a illess or ijury; i this case, copays, coisurace ad deductibles apply. Cotraceptive coverage. Your beefits pla covers wome s cotraceptive methods with o member cost share, icludig two visits per year for patiet educatio ad couselig o cotraceptives. Geeric cotraceptives are covered with o member cost share whe they are: Approved by the Food ad Drug Admiistratio (FDA). O your pla s preferred drug list (also called a formulary). Filled at a i-etwork pharmacy. I additio, your beefits pla covers the member share whe your provider bills for the followig services separately from other services: Admiistratio of certai cotraceptives, such as the isertio of IUDs or ijectios Wome s sterilizatio procedures Preatal care ad breastfeedig. You wo t have to pay aythig for your routie preatal visits provided by a i-etwork provider. You will pay your ormal cost share for delivery, postpartum care, ultrasouds or other materity procedures, specialist visits ad certai lab tests, though. Eve if your pla does t cover materity care, it will cover the prevetive preatal visits. If you eed support with breastfeedig, your beefits pla will cover up to six visits with a lactatio cosultat, at o cost to you. Check with your i-etwork OB/GYN or pediatricia, who may offer these services through their offices. Your pla also covers: A certai selectio of stadard electric pumps (o-hospital-grade) withi 60 days of birth, oce every three years, or A certai selectio of maual breast pumps withi 12 moths of birth, if you have ot received a electric or a maual breast pump i the last three years. Aother set of breast pump supplies, if you get pregat agai before you are eligible for a ew pump. 1. These chages go ito effect whe plas become effective or reew o or after August 1, Employers with gradfathered plas may choose ot to cover some of these prevetive services, or to iclude cost share (deductible, copay or coisurace) for prevetive care services. Certai religious employers ad orgaizatios may choose ot to cover cotraceptive services. Other Pregacy Services. Additioal services for pregat wome iclude: Aemia screeigs. Bacteriuria uriary tract or other ifectio screeigs. Rh icompatibility screeig, with follow-up testig for wome at higher risk. Hepatitis B couselig (at the first preatal visit). Expaded couselig o tobacco use. Breastfeedig itervetios to support ad promote breastfeedig after delivery. 2. Brad-ame cotraceptive drugs, methods or devices are oly covered with o member cost-sharig uder certai limited circumstaces. 6

8 Well-woma care. Most plas already cover well-woma care, with o member cost share. Well-woma care icludes couselig about importat health issues, as well as screeigs for: Breast cacer (mammography every 1-2 years for wome over age 40) Cervical cacer (for sexually active wome) Chlamydia ifectio (for youger wome ad other wome at higher risk) Goorrhea (for all wome at higher risk) Iterpersoal or domestic violece Osteoporosis (for wome over age 60, depedig o risk factors) Alcohol misuse, obesity ad tobacco use Blood pressure Cholesterol (for adult wome of certai ages or at higher risk) Colorectal cacer (for adult wome over age 50) Depressio Type 2 diabetes (for adult wome with high blood pressure) or gestatioal diabetes (icludig screeig durig pregacy) HIV Syphilis Immuizatios. Doses, recommeded ages ad recommeded populatios vary. Covered immuizatios iclude: Diptheria, pertussis ad tetaus (DPT) Hepatitis A ad B Herpes zoster Huma papillomavirus (HPV) Iflueza Measles, mumps ad rubella (MMR) Meigococcal (meigitis) Peumococcal (peumoia) Varicella (chicke pox) 7

9 ASBAIT PPO Network BCBS of Arizoa. Your pla s Preferred Provider Orgaizatio (PPO) etwork does ot require the selectio of a Primary Care Physicia (PCP), or are referrals required i order to receive medical services. Importat: The Arizoa School Boards Associatio Isurace Trust (ASBAIT) Pla cotracts with BlueCross/BlueShield of Arizoa to use their PPO Network. This medical beefits pla is provided exclusively by ASBAIT ad the member school district with claims beig paid by Meritai Health. BlueCross/BlueShield of Arizoa is ot the ame of this pla or is it the isurace carrier. Special poits of iterest: Whe you eed to see your doctor let them kow that you have BCBS of AZ ad preset your ASBAIT medical/rx card upo your visit. By receivig your care ad services from a provider i the BlueCross/BlueShield of Arizoa Network, you will receive a higher level of beefits (i-etwork) ad therefore have less out-of-pocket expeses. The pla/ppo etwork does ot require the selectio of a PCP, or are referrals required i order to receive medical services. If the eed for emergecy medical care occurs whe travelig outside the pla s etwork, beefits will be paid as i-etwork beefits if medical attetio was required due to a accidet or illess which was serious eough to costitute a emergecy as defied i the Pla Documet. Refer to your schedule of beefits for major medical services ad beefits. Blue Cross/Blue Shield of Arizoa. Visit Provider Search: Choose ID Cards without alpha prefix. Support for your health jourey. ASBAIT ad your employer wat you to get the best, most appropriate care, whe ad where you eed it. That s why your pla icludes the extra expertise of ASBAIT s Medical Maagemet program. The Medical Maagemet urses are like persoal health cosultats who ca help you make decisios about certai types of care you ad your doctor may be cosiderig. Registered urses review treatmet plas, the help to assure that you get the right treatmet i the right settig, whe you eed it. Before you get care, call Medical Maagemet. The followig items ad/or services must be precertified before ay medical services are provided: Chemotherapy: All settigs icludig services redered i a physicia s office. Dialysis: All settigs icludig services redered i a physicia s office. Durable Medical Equipmet i excess of $1,500. Hospice care Ipatiet admissios, icludig ipatiet admissios to a skilled ursig facility, exteded care facility, rehabilitatio facility ad ipatiet admissios due to a metal disorder or substace use disorder. Radiatio: All settigs icludig services redered i a physicia s office. Imagig, limited to the followig: CT/MRA/MRI/PET scas, scitimammography, capsule edoscopy ad U.S. boe desity (heel). Morbid obesity surgery Trasplats Outpatiet surgical procedures, icludig surgery redered i a physicia s office. Pai maagemet ijectios, icludig services redered i a physicia s office. ASBAIT Medical Maagemet. Cotact a Medical Maagemet Nurse at: ASBAIT or

10 How to obtai precertificatio: For o-emergecy procedures ad hospital admissios: The covered perso or the physicia must cotact Medical Maagemet prior to the admissio or i advace of the procedure. Medical Maagemet will review the request for services ad cotact the physicia for ay records or additioal iformatio ecessary to thoroughly evaluate the eed for services. For emergecy procedures or hospital admissios: The covered perso, the physicia, the hospital admissios clerk or ayoe associated with the covered perso s treatmet, must otify Medical Maagemet by telephoe withi 48 hours of the procedure or admissio. Precertificatio of a procedure does ot guaratee beefits. All beefit paymets are determied by Meritai Health, i accordace with the provisios of this pla. The program is desiged as a cost-cotaimet program to maximize the pla beefits ad reduce uecessary hospitalizatios, surgical procedures ad other diagostic services. Oce a precertificatio has bee received, it is valid for a period of 90 days. Failure to comply. Failure to comply with the precertificatio requiremets may result i pealties which you will be resposible for. A 20% reductio i beefits may be take, or you may be disqualified from beefits altogether. Your doctor may request precertificatio for you, however you are ultimately resposible for makig sure precertificatio is obtaied whe required. O-site biometric screeigs. A biometric is a measure of your body s performace ad health. If your employer agrees to participate, we come to you at your work place to help you get a picture of your curret health. The program is volutary. Here s how it works. Professioals from Iteractive Health Solutios (IHS), a Meritai Health parter, will coduct a health risk assessmet a cofidetial survey about your persoal health ad history right at your work place. I a private settig, they ll draw a blood sample for a blood chemistry profile. This will be used to measure more tha 34 factors that determie your health today. They will also take a blood pressure readig. Oce you ve completed the blood draw, you ll be able to view a persoalized, cofidetial report showig your results. The report will iclude ay heads-up messages about areas you might eed to discuss with your doctor. 9

11 A prescriptio for a healthier budget. Whe you eed prescriptios filled, you have your easy-to-use prescriptio drug beefit. But to get the most from your beefits pla, it pays to be a wise cosumer. Your prescriptio drug beefit is admiistered by Catamara. Cotrollig your prescriptio copay. I may cases, you ca cotrol how much your share of costs will be whe you fill a prescriptio. How? Geeric drugs cost less to maufacture, ad they re just as effective as the ame brads. You ll save moey whe you request them because geerics have a lower copay tha preferred or o-preferred drugs. Visit for a drug formulary, which lists which drugs are cosidered preferred or o-preferred. Prescriptio drug copays: Retail Pharmacy 30-day supply Mail Order 90-day supply Madatory geeric $15 $30 Preferred brad-ame* 20% 20% (whe o geeric is available) ($20 mi; $75 max) ($40 mi; $150 max) No-preferred brad-ame* 30% 30% (whe o geeric is available) ($35 mi; $100 max) ($70 mi; $200 max) *Please ote: If you purchase a brad-ame drug while a geeric is available, you will be charged the brad-ame copay PLUS the cost differece betwee the geeric ad the brad-ame drug. Why geerics make sese ad dollars. Because compaies that develop ew drugs have log-term patet protectio for their products, other drug compaies are preveted by law from maufacturig those drugs eve if they ca produce them less expesively. Whe patets expire, other compaies ca make equivalet drugs, usually at a much lower price. Geeric equivalets go through rigorous FDA testig regularly to assure that they are just as effective as the brad-ame drugs. Cosider all of the compellig reasos to protect your pocketbook with the lower-price geeric drugs: Geerics ca cost up to 75 percet less tha their brad-ame equivalets. FDA testig is exactly the same for geeric ad brad-ame drugs. Geerics cotai the same active igrediets as the origial, brad-ame drug, i the same amouts ad dosages. Geeric drugs sometimes look differet from the origial brad-ame drug i color or shape, but oly because they may have differet iactive igrediets that wo t chage how the drug works. Nearly half of all brad-ame drugs have geeric equivalets but you may have to ask for them. Geerics have the lowest copay uder this pla, so you save o every prescriptio. Catamara. Cotact the Pharmacy Help Desk / Customer Service at: Prior authorizatio. If your prescriptio is subject to prior authorizatio or step care, the pharmacist will make cotact with the prescriber. You may also cotact Catamara Customer Services at (same phoe umber as the Pharmacy Help Desk) for more iformatio. For questios about... You may call... At this umber: Prescriptio drug beefits Catamara Cliical Prior Authorizatio

12 Alliace Work Parters: Your Employee Assistace Program. Alliace Work Parters (AWP) is your EAP provider, offerig you ad your family valuable, cofidetial services at o cost to you. Desigated to help you maage daily resposibilities, life evets, work stresses or issues affectig your quality of life, AWP is available to take your call 24 hours a day, 7 days a week. Key provisios of the EAP: 1-5 short term couselig sessio per problem per year, which icludes assessmet, referral ad crisis services. Depedets ad parters residig i the employee s household are covered. The EAP is available at o cost to the employee or family member ad is cofidetial. Legal ad fiacial services Work Life services Nurselie HelpNet services access to olie materials The EAP urselie: Call aytime, day or ight! What do you do whe you re ot sure WHAT to do?: Whe you do t kow where to go for care (is it really a emergecy?). Whe it s 4 a.m. ad your child ca t stop coughig? Whe you ve take a tumble ad your akle is swellig? Now you ca call the EAP Nurselie to talk to a registered urse who will liste ad give you professioal, seasoed advice, makig sure you get care i the right place at the right time. Oe more great support feature for pla participats: Our urse couselors ca coect you to commuity resources, like support groups, classes ad semiars. Guidace ad cofidetial couselig for you ad your family: Stress Health Relatioships Family Drugs Alcohol Emotioal Health Ad aythig else affectig your quality of life. Alliace Work Parters. For further iformatio or assistace regardig this beeficial program, cotact AWP. Toll free: TDD: eap@alliacewp.com Visit your EAP website at alliacewp.com. Create a customized accout by goig to: Go to Click logi at the top right: Iitital logi: ASBAITmember Password: AWP4me (case sesitive) You will be prompted to create your ow uique userame ad password. EAP Tee Lie: TEEN (8336). Safe Ride Program. For those occasioal momets whe callig a cab is the right thig to do, the Safe Ride Program is available aother FREE ad CONFIDENTIAL program for you ad your family. AWP will reimburse the cost of cab fare (up to 50 miles oe way) whe you choose to call a cab rather tha drive or ride with someoe who has had too much to drik. For more details please call AWP s 24-hour toll-free umber:

13 Claims ad customer service iformatio Balacig healthcare costs: What you pay ad what the pla pays. Your Beefits Schedule shows how much you pay for care, ad how much the pla pays. It s a listig of what is ad is t icluded i your beefits pla. For more detailed iformatio, see your summary pla descriptio (SPD). For example: After you pay your aual deductible ad ay up-frot copays, the pla begis to pay a percetage of your provider s charges, for example 80%. The remaiig percetage, for example 20%, is your resposibility your out-of-pocket costs. You re protected from fiacial hardship by a maximum out-of-pocket amout each year the most you ll have to pay before the pla covers costs at 100%. (Copays do ot always apply to the out-of-pocket maximum. This varies by pla). Claims ad customer service. Meritai Health has bee the claims admiistrator for ASBAIT sice All claims adjudicatio ad customer service iquiries are hadled by Meritai Health staff members. Correspodece regardig your claims will be set from our office. The goal of our Customer Service departmet is to esure that school employees uderstad their pla features ad receive immediate assistace regardig claims issues, from a highly-qualified ad traied staff member. You will be treated with respect, as we are resposible to you for first call resolutio with results. It is our goal to ot oly meet, but exceed your expectatios. If you have ay questios regardig your beefit pla(s) please cotact Meritai Health Customer Service at , or toll free at Claim submissio. Mail your claim forms ad attachmets to: Meritai Health P.O. Box Mieapolis, MN Importat phoe umbers: For questios about... You may call... At this umber: ASBAIT beefits Meritai Health or Flexible Spedig Accouts Customer Service Prescriptio drug beefits Catamara Cliical Prior Authorizatio Precertificatio ASBAIT Medical Maagemet ASBAIT or EAP/Nurselie Alliace Work Parters (AWP) Health U-Safe U Welless Program Edwards Risk Maagemet

14 24-hour access to tools you ca really use at The Meritai Health member website, is desiged to provide a secure, user ad family-friedly, oe-stop-shop for you to access the accout ad claims iformatio you ca use to maage your health ad welless. We re committed to providig you with all the basics you expect, alog with added features to support a healthy lifestyle, assist you with medical decisios, ad give isight ito the maximizatio of your healthcare dollars. Go to mymeritain.com to log i to our secure site. Retur users, just sig i usig your userame ad password. The first time you access the site, you will be prompted to re-register with a ew userame ad password for ehaced security. The take advatage of the smart, safe resources your health pla offers, right at your figertips. New users ca create a accout by followig the easy istructios. You ll eed your health pla ID Card the first time. Remember, each member of your family ca have a accout, too. Privacy Regulatios. Members over 18 years of age have partially protected iformatio accordig to HIPAA Privacy Regulatios. Members over 18 havig difficulty creatig a accout with their SSN, please cotact Meritai Health Customer Service at , or toll free at At mymeritain.com you ca: Look up health ad welless topics i our olie medical library. Keep track of your flexible spedig accout (FSA). Fid the status of a claim. Fid etwork doctors, cliics ad hospitals. Look up prescriptio ad over-the-couter drug iformatio. Order ID Cards. 13

15 Trust the People Who Care for You About ASBAIT. The Arizoa School Boards Associatio Isurace Trust or ASBAIT was established i 1981 by the Arizoa School Boards Associatio. Its formatio was i respose to Arizoa school admiistrators desire to obtai comprehesive health beefits at reasoable costs. Meetig the eeds of employees ad their depedets is at the core of ASBAIT's philosophy. These factors differetiate ASBAIT plas from commercial employee beefit programs makig it the umber oe choice with Arizoa schools. Missio statemet: The missio of the Arizoa School Boards Associatio Isurace Trust (ASBAIT) is to set the stadard for service, beefits, ad affordability for the healthcare of Arizoa s school employees ad their depedets. Goverace: ASBAIT was set up ad operates by a "Agreemet ad Declaratio of Trust" i accordace with the laws of the State of Arizoa, icludig, without limitatio, Arizoa Revised Statutes Sectio as it may be ameded from time to time. Operatioal authority of the Trust is by the Board of Trustees. The Board of Directors of the Arizoa Associatio of School Boards appoits the Trustees. The Trustees cosist of at least oe school district goverig board member, at least oe superitedet of a school district, ad at least oe school district busiess maager. The Trustees meet four to six times per year (schedule of meetigs are listed elsewhere) to coduct the busiess of the Trust. Their major resposibilities iclude approvig rate ad reewals for members; overall budget; cotractors; ad idepedet fiacial audit. The Trustees may also hear ad make decisios o appeals or exceptios for claim paymets to member employees or depedets. ASBAIT fast facts: Sice 1981 ASBA has sposored this self-fuded beefit program that is exclusive to Arizoa school districts ad commuity colleges. ASBAIT covers over 35,000 employees ad their depedets. Curretly there are over 175 participatig schools. 14

16 Appedix Glossary Claim forms Glossary of terms. Certificate of Creditable Coverage. A certificate issued by a employee s former health pla that verifies the legth of creditable coverage for purposes of shorteig or elimiatig a pre-existig limitatio period. See creditable coverage. Creditable coverage. Previous health pla beefits that may be applied to shorte or elimiate a pla participat s pre-existig limitatio period for a pre-existig coditio. Most types of health isurace, icludig group health plas, COBRA coverage, HMO, idividual health isurace policies, Medicaid ad Medicare, are cosidered creditable coverage. Copay. A amout of moey that a participat is required to pay each time he or she visits a healthcare provider or fills a prescriptio. Coisurace. A percetage of the billed amout that you are resposible for o a service or procedure (after you have met the aual deductible). Coisurace is differet from copays ad deductibles i that the pla will pay a desigated percetage of charges util the aual out-of-pocket maximum is reached. Deductible. The aual out-of-pocket amout that a pla participat is resposible for payig before the health pla covers his or her medical costs accordig to the terms of the pla. Util a perso meets the aual deductible, he or she pays the full cost of healthcare services received, uless the service is ot subject to the aual deductible as stated i the beefit schedule. mymeritain.com. Your olie health iformatio portal ad your persoal coectio to your pla. Here you ca order prescriptios, fid healthcare providers, research health topics ad get aswers to your questios about healthcare. The persoal iformatio used to access is cofidetial. You may eed the iformatio o your ID Card to log i for the first time. Preferred Provider Orgaizatio (PPO). Orgaizatio that egotiates special, lower rates for healthcare services provided by physicias ad other care providers who are withi the PPO s etwork. Providers who belog to a PPO are called participatig or i-etwork providers. Out-of-pocket maximum. A limit to the total amout of coisurace ad deductible expeses you will icur each year. Oce you meet your out-of-pocket maximum, the pla will pay at 100% for the remaider of the year. Usual ad customary charge. Your pla reimburses charges from o-participatig or out-of-etwork providers that are equal to, or less tha, usual ad customary charges. Usual ad customary charges are the amouts most frequetly charged for the same service: I the same geographic area; ad By other providers i the same or similar medical area. The fees charged by o-participatig providers may exceed the usual ad customary charges recogized by your pla. I such cases, Meritai Health will process a amout equal to the usual ad customary charge for the healthcare service you received, ad you will be reimbursed for a portio of that amout accordig to your pla s out-of-etwork beefits. 15

17 Health Claim Form Complete ad sed to: ASBA Isurace Trust P.O. Box Mieapolis, MN Fax: IMPORTANT: Please have your doctor or supplier of medical services complete the reverse of this form or attach a fully itemized bill. A diagosis must be show o bill. Do ot submit this form if ijury occurred o the job. Please cotact the Workers Compesatio Carrier/Admiistrator for proper istructios regardig a work related claim. Sectio 1. EMPLOYEE INFORMATION Name (last, first, iitial) Sex Employer Name Home Address Idetificatio Number Birthdate Group Number City State Zip Code Work Telephoe ( ) Sectio 2. PATIENT INFORMATION The patiet is: The employee Employee s Spouse Home Telephoe ( ) Employee s Child (Complete spouse ad child iformatio) (Go to sectio 3) (Complete spouse iformatio) Spouse s Name (last, first, iitial) Sex Child s Name (first, last, iitial) Sex Spouse s Birthdate Spouse s Social Security Number Child s Birthdate Child s Social Security Number Spouse s Employer Spouse s Employer s Address Sectio 3. OTHER COVERAGE If child is over age 19 ad full-time studet, complete: Name of School: School Address Yes (the complete) No (go to sectio 4) Name of Policy Holder: Name of Other Health Isurace Carrier or Pla Address City State Zip Code Other Isurace Carrier s or Pla s Telephoe # Spouse s Employer Spouse s Employer s Address Sectio 4. ABOUT THIS CLAIM Ijury Illess Date ad time of accidet: Type of Coverage Group Idividual Was this ijury the result of a accidet? Yes No If auto isurace was ivolved, please provide: Was this a work-related ijury? Yes No Group Number If child is over age 19 ad full-time studet, complete: Name of School: School Address Describe ijury, whe ad how it happeed or ature of illess: Cotract or Policy Number Policy # Name of isurace compay Address (city, state, zip) If ijury is work-related, please cotact the Workers Compesatio Carrier/Admiistrator for proper istructios regardig this claim. EMPLOYEE S (or adult depedet s) SIGNATURE REQUIRED The statemets above are true ad correct to the best of my kowledge. I authorize ay provider of services to furish ay iformatio requested to the Beefit Admiistrator. I also authorize the Beefit Admiistrator to release or obtai from ay orgaizatio or perso iformatio that may be ecessary to determie beefits payable uder the Beefit Pla. A photo-static copy of this authorizatio shall be cosidered as effective ad valid as the origial. For ay paymet that exceeds the amouts payable uder the Beefit Pla, I agree to reimburse the pla i a lump sum paymet or by a automatic reductio i the amout of future beefits that would otherwise be payable. Sigature: Date: ASSIGNMENT OF BENEFITS (complete this sectio if provider is to be paid directly) I authorize paymet of beefits to the doctor or supplier of services listed here. Provider to be paid Provider s tax ID umber or Social Security Number Employee s Sigature Date

18 A B C IMPORTANT: Please have your doctor or supplier of medical services complete the reverse of this form or attach a fully itemized bill. Patiet Name (last, first, iitial) Birthdate Address Is this coditio the result of a ijury arisig from patiet s employmet? Yes No If yes, please cotact the Worker s Compesatio Carrier/Admiistrator for proper istructio regardig this claim. If yes, expected date of delivery D Pregacy? Yes No E F G If illess, date of first treatmet If treatig ijury, date of ijury Name of referrig physicia Referrig physicia s address Name ad facility where services were redered (if other tha home or office) H Was laboratory work performed outside your office? Yes No For service related to hospitalizatio, give dates: I Admitted Discharged Diagosis ad curret coditios (if diagosis other tha ICD-9* used, give ame): 1. J Dates of Service From To Places of Services** Procedure Code (If other tha CPT*** code used, give ame) Descriptio of surgical or medical services redered Diagosis Code Charges K *ICD-9 * Iteratioal Classificatio of Disease **Abbreviatios: 11-Physicia s Office 12-Ipatiet Hospital 23- Emergecy Room *** CPT Curret Procedural Termiology (curret editio) 12-Patiet s Home 22-Outpatiet Hospital 81-Idepedet Laboratory Date Physicia s Name (prit) Degree Provider s Tax ID Number or Social Security Number: Physicia s Sigature Telephoe Must be furished uder authority of law ( ) Street Address City State Zip Code

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