Eligibility and Enrollment

Your district Treasurer will be able to tell you when you are eligible to enroll and has the appropriate enrollment forms.  If you acquire a new dependent through birth, adoption or marriage, you must complete an enrollment form for them within 31 days of the event for them to be covered.  If you want to make changes in who is enrolled, you can do this during open enrollment which is at the beginning of the school year.  Changes made during open enrollment are effective October 1.

Claims

Most providers will submit claims for you. For those claims you send in yourself, claim mailing addresses are included on each plan page.  Keep copies of your claims.

Problems?  Questions?  If you have a problem with a claim:

1)  Look up your claim on the carrier’s website.  This is the quickest way to see if they have received the claim and what they did with it.

2)  Contact Customer Service.  Each carrier’s Customer Service number is shown on their plan page.

3)  Keep a record of who you talked to, when and what was agreed to.

This will resolve most problems.  If you still need help, contact us at the EPC Benefits Office 890-3725, 1-800-589-6684 or ep_benefits2@mdeca.org.

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Continuation of Coverage  (COBRA) – If you lose coverage or When your dependent is no longer a dependent.

If an individual no longer qualifies as a dependent due to divorce, a child exceeding the age limit, graduating from school or not qualifying as an IRS dependent, you can continue the benefit plans for up to 36 months.  You will be responsible for paying the full premium plus a small administrative fee.  This is called COBRA coverage – in reference to the federal legislation behind it.

COBRA coverage for an 18-month period is also available to most employees who lose coverage.

If you or your dependents are eligible, there are time limits specifying when you can apply for COBRA.  It is your responsibility to notify the Treasurer’s office of any changes affecting dependent’s eligibility which would make them eligible for COBRA.  Refer to your plan booklets for full details and contact the Treasurer’s office for application forms.

Emergency Care

Know your emergency care benefits and the location of urgent care centers near you before you need to use them.

Hospital emergency rooms are for apparently life threatening conditions which have developed suddenly.  Emergency room bills will not be covered for routine medical care.  If you are admitted to the hospital from the ER, the ER co pay will be waived.

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Provider Networks

The United Healthcare Plus Plan, the UHC HMO and the Anthem PPO plans are all network based managed care plans.  In other words, there are lists of medical providers (hospitals, doctors, laboratories etc.) who have contracts with UHC or Anthem.  These are referred to as network providers.  The following are the benefits of using network providers:

1)      The provider will submit claims and should also resolve claim problems for you.

2)      For most expenses from network providers you owe only a flat co pay amount.

3)      The carriers have negotiated providers’ fees so you will not be billed for amounts over “reasonable & customary.”

4)      You don’t need a referral from a primary care doctor to consult a specialist.

5)      Benefit levels are higher for network providers.

The UHC Plus Plan and Anthem PPO also cover providers who are not in the network, however, the benefit level is lower and your costs will be higher.  If you use Out of Network providers you will be responsible for claim submission and deductibles and coinsurance amounts. Bills are paid based on Reasonable and Customary fees as determined by the carriers.  Out of Network providers can bill you for amounts that are over the R&C amount.

Minimize your cost by using network providers.  If you need other services like lab tests or hospitalization, your Out of network doctor can send you to a network facility and those bills will be paid at the higher network benefit level.

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