III.
Medical Benefit Overview
This section describes
general facts about your TeamstersCare health coverage.
It’s important
for you to know the general information in this particular
section of your Answerbook.
TeamstersCare
Medical Benefit Options:
General Information
TeamstersCare provides basic medical
benefits through:
• TeamstersCare
Network Blue New England Option
• TeamstersCare
Tufts Exclusive Provider Option (EPO)
• TeamstersCare
Tufts Out of Area Option
Each of these Options
offers a wide range of health services, including doctors’ visits,
hospitalization, surgery, maternity care—and many other
medical products and services.
Your own coverage depends on where
you live. To participate in a particular HMO, you must
live within that HMO’s network service area. If you
and your eligible dependents live in an area covered by
both TeamstersCare HMO’s, you may choose either one.
If you and your eligible dependents live in a service area
covered by only one of the HMO’s, you may participate
in that HMO only.
Finally, if you or any one of your
eligible dependents lives in an area not covered by either
HMO, then you and all your dependents will automatically
be covered by the TeamstersCare Tufts Out of Area Option.
(You cannot elect the Out of Area Option if you and all
your eligible dependents permanently reside in one of the
TeamsterCare HMO network service areas.)
If you’re a member of a TeamstersCare
HMO, you will need to select a Primary
Care Physician (PCP) for yourself
and for each covered family member. Your individual PCP
will coordinate all your routine care and guide you through
any referrals you may need for specialized services. If
you’re a member of the Out of Area Option, you do
not have to select a PCP. When you use a participating network provider, the Out of Area
Option covers most services in full, after you make certain
copays. If you use a non-network
provider, most expenses are covered at 80% of allowable amounts.
Once enrolled, the one Option you
elect covers you and all your eligible dependents. You
must remain in that Option until the end of the calendar
year, unless you have a qualifying change in family status.
If you’re currently in TeamstersCare’s
Network Blue, or Tufts EPO, or the Tufts Out of Area Option,
and you or an eligible dependent permanently moves out
of that particular provider’s service area, then you must call Charlestown
Member Services to discuss changing your medical benefit
Option. The only exception to this rule is if a dependent
temporarily moves out of the service area. In this case,
your dependent will continue to be covered by your current
medical Option. For more specifics, contact your HMO directly.
TeamstersCare
HMO’s: General Information
If you participate
in either of TeamstersCare’s two HMO’s, refer
to your HMO booklet for specific details of your coverage.
In general:
• HMO’s
will not cover the expense of any non-emergency services
you receive
outside the HMO’s network.
• You’ll
select a Primary Care Physician (PCP)—the individual
professional who’s principally responsible for coordinating
your medical care. Check the physician directories pertaining
to the TeamstersCare HMO’s available physicians in
your area. Your current doctor might already be a PCP for
one or both of the HMO’s offered. For more information,
see When to Contact Your HMO & Charlestown Member Services, p. 33.
• Each of your
family members receives medical care from his or her individual
PCP. When specialized care is needed, the PCP coordinates
all referrals to practitioners within the HMO network. It’s
especially important to maintain this relationship. Except
for life-threatening emergencies—and other specific
circumstances defined by each HMO—TeamstersCare HMO’s
pay benefits for services only when provided or referred
by an individual’s PCP.
• You do not have
to pay deductibles or coinsurance or fill out claim forms—though
in most cases you will be responsible for making a copay.
• If you’re
a new Plan member, your HMO coverage begins after you become
eligible and then enroll for TeamstersCare benefits. Your
eligible dependents are covered as of that same date.
• If you elect
a TeamstersCare HMO during the Annual Enrollment period,
then your coverage in that HMO begins January 1 of the following
year.
TeamstersCare
Tufts Out of Area Option: General Information
If you or your eligible
dependents permanently reside outside of both HMO service
areas, you will be covered by the TeamstersCare Out of Area
Option. Tufts Health Plan administers this Option for TeamstersCare.
Contact Tufts Health Plan at 1-888-679-0936 for a booklet
that provides specific details about the Out of Area Option.
Or you may visit their website at www.phcs.com.
In general:
• The TeamstersCare
Out of Area Option uses the Private Healthcare Systems® (PHCS)
network. PHCS appears on your ID card.
• The Option pays
100% of the cost of most covered services when you use a
PHCS provider. However, you’ll need to make copays
for certain specific services.
• You will receive
a PHCS Provider Directory with information
specific to the area where you live. To receive the PHCS
network level of coverage, you must use providers and facilities
listed in the Directory.
Use the Directory or simply call your doctor’s office
to see if your current doctors are part of the network.
• After you enroll,
you will receive an ID card. Whenever you use any PHCS network provider
(listed in the Directory), simply show your ID card and make the appropriate copayment at the time of your visit. When you use a
PHCS network provider, there are no deductibles or coinsurance,
and no claim forms to file.
• If you or a
covered dependent uses a non-network provider, most services
are covered at 80% of reasonable and customary amounts. (“Reasonable and customary amounts” are the usual
fees that healthcare providers charge for similar services.)
You are responsible for: (1) paying the balance—which
may include charges that exceed reasonable and customary
amounts and (2) filing a claim form for reimbursement of
non-network services.
• If you’re
a new Plan member, your Out of Area coverage begins on the
same date that you become eligible for TeamstersCare coverage
and you enroll. Your eligible dependents are covered as of
that same date.
• If you switch
from a TeamstersCare HMO Option to the Out of Area Option,
then your coverage begins the first of the following month
after you enroll.
Choice
of Medical Option for the Calendar Year
Once you have enrolled
in one of the TeamstersCare Medical Options, your choice
extends through the calendar year, January through December.
You cannot switch Options until the next Annual Enrollment
period unless you have a qualifying event. (See Qualifying Events, click
here for details.)
TeamstersCare
Clinical Services Benefits: General Information
Regardless of which
TeamstersCare Option provides your basic medical coverage,
your family also has access to a variety of important services
that TeamstersCare makes available through its own dedicated
facilities or through specialized providers.
These services include:
• pharmacy and
prescription drugs
• dental care
• vision care
• hearing care
• mental health &
substance abuse care
• wellness programs
and adult health screenings
FImportant
Note: Regardless of which TeamstersCare Medical Option you
choose, these clinical services are made available to you
by TeamstersCare, not by either HMO or by the Out of Area
Option.
TeamstersCare
Coverage: Lifetime Maximum
Each participant (member and dependents)
covered by the TeamstersCare Active Medical Program has
a $1,000,000 lifetime benefit maximum, per individual.
This maximum includes all benefits paid by Teamsters
Union 25 Health Services &
Insurance Plan.
Coordinating TeamstersCare
Health Benefits with Other Medical Benefit
TeamstersCare needs to ensure
that healthcare benefits are made available to you and
your family as cost-effectively as possible. By coordinating
TeamstersCare coverage with other medical plans, we create
efficiencies that may often result in full coverage for
you or lower out-of-pocket costs.
If you or a family member has medical, dental, or prescription
drug coverage under some other benefits plan (for example,
your spouse’s employer’s medical plan,
or COBRA, or Medicare), you must notify TeamstersCare
about this coverage. Any benefits you receive from
that other plan will be “coordinated”
with benefits you’re eligible to receive from
TeamstersCare. For a detailed explanation of how your
TeamstersCare benefits are coordinated with other benefit
coverages, see Coordination
of Benefits, click
here.
Medical
Benefits for Motor Vehicle and Motorcycle Accidents
If you have a medical claim related
to a motor vehicle or motorcycle accident, you (or someone
acting on your behalf) must notify TeamstersCare as soon
as possible. TeamstersCare’s coverage varies with
a number of factors. In all cases, you will have to sign
an agreement obligating you—should you or any of
your dependents receive any third-party settlements—to
reimburse TeamstersCare for any money the Plan may have
paid out for claims relating to that accident.
States Requiring Mandatory No-Fault
Insurance
If you live in
Massachusetts, or any other state with mandatory no-fault
insurance, and you are covered
by such insurance, then any medical claim or lost wages resulting
from a motor vehicle accident are covered
by the mandatory no-fault insurance. The no-fault policy
may be liable for medical, prescription drug, dental benefits,
and/or lost wages, up to the first $8,000 of expenses—or
the maximum amount called for by law, whichever is greater.
After this amount is paid, TeamstersCare may then cover any
remaining eligible healthcare expenses.
FImportant
Note: If the no-fault insurance denies the first $8,000 of expenses
due to driving under the
influence, TeamstersCare will
cover only those eligible health care expenses above $8,000.
If no-fault insurance is available
but you decline the coverage, and you have a medical claim
resulting from a motor vehicle or motorcycle accident, you
will be responsible for the first $8,000 of expenses—or
the maximum amount that no-fault insurance would have paid,
whichever is greater. TeamstersCare excludes coverage for
all amounts that would have been covered had you obtained
no-fault insurance.
FImportant
Note: Mandatory no-fault insurance generally does not cover
motorcycle accidents.
Other States
If you live in
a state that does not require mandatory no-fault coverage,
the Plan will administer motor vehicle and motorcycle accident
medical or disability claims in the same way as any other
claim. However, if you receive any third-party settlements
after signing a lien agreement, you will be required to reimburse
TeamstersCare an amount equal to any payments the Plan may
have made on your behalf.
Continuing
Medical Coverage under COBRA
If you lose eligibility
for TeamstersCare medical benefits because of a “qualifying
event,” you can continue your health coverage under
a Federal law called COBRA (Consolidated Omnibus Budget Reconciliation
Act of 1985). For details on COBRA coverage, see SECTION
VII.
FImportant
Note: During the period when you are covered by COBRA, TeamstersCare
will provide benefits for prescription drugs; mental health
and substance abuse; hearing care; and adult health screenings.
You may also elect to continue dental and vision coverage
through COBRA by paying a higher monthly premium. However,
please note that the TeamstersCare Weekly Disability, Life,
and AD&D coverages are not available under COBRA.
Health
Benefits TeamstersCare Doesn’t Cover
Certain healthcare
expenses are not covered by the TeamstersCare HMO’s
or Out of Area Option. If, in reading this Answerbook and the Medical
Option booklets, you don’t find a particular service
described as being covered, it’s
safest to assume it is not offered as a TeamstersCare benefit.
Contact your HMO, or Tufts in the case of the Out of Area
Option, for any questions you may have about specific coverages
that are not addressed in your booklet. |
