Teamsters Union Local 25 Health Services & Insurance Plan

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IV. TeamstersCare Basic
Medical Benefit Options

The information in this particular section of your Answerbook supplements the information in your Medical Option booklets. For details on covered expenses and benefit levels under the individual TeamstersCare HMO’s and the TeamstersCare Tufts Out of Area Option, you’ll need to read the booklets for those particular Options.

The TeamstersCare HMO’s: Overview

TeamstersCare has contracted with two Health Maintenance Organizations (HMO’s): TeamstersCare Network Blue New England and TeamstersCare Tufts Exclusive Provider Option (EPO).

An HMO contracts with individual hospitals, doctors, and other health practitioners to provide services at reduced costs to members of that particular HMO. Typically, HMO’s place special emphasis on preventive or “maintenance” healthcare.

We selected our HMO’s by researching the needs of our members and evaluating the service and quality of the best available providers. We will continue to monitor the service our HMO’s provide and periodically reevaluate our selection.

Besides your basic HMO coverage, TeamstersCare makes the following clinical services available to you:

• pharmacy and prescription drugs

• dental care

• vision care

• hearing care

• mental health & substance abuse care

• wellness programs and adult health screenings

These services are provided by TeamstersCare, not by the HMO’s.

Your TeamstersCare HMO Options

Depending on where you live, you may have the option of enrolling yourself and your family in one of the following two HMO’s:

TeamstersCare Network Blue New England Option
This is TeamstersCare’s version of HMO Blue, an organization available in the New England states of Massachusetts, New Hampshire, Connecticut, Rhode Island, Vermont, and Maine.

The Teamsters Union 25 Health Services & Insurance Plan self-funds the benefits it provides through TeamstersCare Network Blue New England. Network Blue New England provides members with medical benefits according to its contract with TeamstersCare and handles the administrative services needed to support the delivery of benefits.

You can contact Network Blue New England at:
Blue Cross Blue Shield of Massachusetts
P.O. Box 9131
North Quincy, MA 02171-9131
Phone: 800-241-0803

Provider directories are available through Charlestown Member Services.

TeamstersCare Tufts Exclusive Provider Option (EPO)
This is TeamstersCare’s version of the Tufts Health Plan, available in Massachusetts, Rhode Island, and certain parts of New Hampshire.

The Teamsters Union 25 Health Services & Insurance Plan self-funds the benefits it provides through Tufts EPO. Tufts provides members with medical benefits according to its contract with TeamstersCare and handles the administrative services needed to support the delivery of benefits.

You can contact Tufts at:
Tufts Associated Health Plans, Inc.
705 Mt. Auburn St.
P.O. Box 9171
Watertown, MA 02472

Phone: 866-342-4685

Provider directories are available through Charlestown Member Services.

How the TeamstersCare HMO’s Work

Basically, both TeamstersCare HMO’s provide the same types of general medical services. Each of the TeamstersCare HMO’s is structured differently, and each has its own rules for delivering services. However, they do share certain common characteristics.

For example, when you use an HMO, you pay no deductible or coinsurance. Instead, you pay a $15 copay for each office visit or a $50 copay for each emergency room visit (waived if you are admitted to the hospital directly from the emergency room). You file no claim forms for HMO services.

Your Primary Care Physician
Regardless of which one of the two TeamstersCare HMO’s you join, you’ll have the opportunity to select a particular doctor to serve as your Primary Care Physician (PCP). You and all your family members must enroll in the same HMO. Each of you must select your own individual PCP from that HMO’s physician network.

Your PCP is the one person chiefly responsible for making HMO care available on a 24-hour basis, for seeing that you receive appropriate, timely service, and for coordinating your care with other practitioners when you need special help.

TeamstersCare HMO’s encourage you to develop a close relationship with your Primary Care Physician. This network of relationships is the basis for the HMO model in general, and particularly for the HMO’s emphasis on preventive care.

FImportant Note: It is very important to choose a PCP at the time you enroll in an HMO. Until you choose a PCP, you are covered only for emergency care. If you wish to change from one PCP to another, you should contact your HMO directly.

Unless you’re faced with a serious emergency—and any other specific circumstances defined by each HMO—you must obtain a referral from your PCP before seeing another doctor. Otherwise, the HMO will not cover the cost of services you receive from that doctor.

In Case of Emergency
TeamstersCare has one priority in cases of a serious emergency: you or your family member should get help as quickly as possible.

In an emergency, you should seek immediate care, and you (or someone acting on your behalf) must notify your PCP within 48 hours after the emergency treatment or hospitalization begins. The PCP will then monitor and direct your care. If your PCP is not notified within 48 hours, your HMO will not provide coverage.

Benefits HMO’s Do Not Cover

TeamstersCare HMO’s have certain benefit limitations that may vary, depending on the particular HMO. You’ll need to read the HMO booklets for details.

Typically, HMO’s do not cover the cost of:

• emergency care received without required notification to your PCP

• non-emergency treatment not performed or coordinated by your PCP

FImportant Note: The HMO’s do not provide prescription drug, dental, vision, mental health & substance abuse care, or hearing care services to TeamstersCare members. However, as a TeamstersCare HMO participant, these services are available to you and your dependents through our own dedicated TeamstersCare facilities or through other professional providers with whom we’ve contracted. See SECTION V: CLINICAL SERVICES BENEFIT.

Knowing Your HMO

If you enroll in an HMO, make sure you understand the rules and procedures for the particular HMO you’ve chosen. Pay special attention to how your HMO handles or defines the following:

• emergency care

• urgent care

• benefits covered

• benefits not covered

• benefit limitations

• care provided outside of the HMO’s service area

For information on a particular HMO, refer to the HMO booklet and call Charlestown Member Services for a Provider Directory for that HMO. This material contains information about each participating doctor, including name, office address, phone number, and specialty field. The Directory will also indicate whether a particular Primary Care Physician is accepting new patients.

When to Contact Your HMO & Charlestown Member Services

In general, you should contact your own HMO directly when you need information on:

• whether a particular healthcare service or procedure is a covered benefit

• the HMO’s professional staff, providers, and services

• questions related to referrals, claims, or coverage

• emergency procedures

• how to change your PCP

For the addresses and telephone numbers of the TeamstersCare HMO’s,
see Your TeamstersCare HMO Options, click here.

You should contact Charlestown Member Services when you have questions or need information on:

• hours and eligibility

• administrative issues (e.g., enrollment, adding or removing a dependent, address changes, student confirmation letters, COBRA, HIPAA, etc.)

• life insurance, accidental death & dismemberment insurance, dependent life insurance

• weekly disability coverage

• motor vehicle and motorcycle accidents

• your TeamstersCare Clinical Services Benefit (see SECTION V)

• your TeamstersCare Answerbook

FImportant Note: Even if you’re an HMO participant, you should call Charlestown Member Services for an HMO booklet or Provider Directory. You can also contact Charlestown Member Services if you are unable to get an answer or resolve a problem with your HMO.

The TeamstersCare Tufts Out of Area Option: Overview

TeamstersCare has contracted with Tufts Associated Health Plans, Inc. to provide health benefits to eligible members and dependents who do not live within one of our two HMO service areas. If you live outside New England, you are covered by a special medical option called the TeamstersCare Tufts Out of Area Option.

FImportant Note: You cannot elect the TeamstersCare Out of Area Option if you and your eligible dependents permanently reside in one of the TeamsterCare HMO network service areas.

Under this Out of Area Option, you have two general choices for care. (1) You and your eligible dependents can take advantage of discounted services by using a Private Healthcare Systems® (PHCS) network provider. (2) However, you also have the option of using a non-network provider, if you wish to do so.

PHCS Network Medical Coverage

TeamstersCare provides your basic out of area medical coverage through Private Healthcare Systems® (PHCS), an association of medical providers with whom Tufts has contracted on our behalf. When you or a dependent receives covered medical services from a PHCS network provider, in most cases your only cost will be the copay you make directly to your provider.

Non-PHCS Network Medical Coverage

If you do not have convenient access to a PHCS provider, you can go to any other non-network provider of your choice. In this case, PHCS will pay 80% of reasonable and customary amounts for covered services, and you will be responsible for the balance—which may include amounts above reasonable and customary charges. (“Reasonable and customary amounts/charges” are the usual fees that healthcare providers charge for similar services in a given geographic area.)

Clinical Benefits from TeamstersCare Facilities

In addition to your medical coverage under the Out of Area Option, you and your dependents are eligible for the full range of wellness, dental, and pharmacy services available at our Charlestown, Chelmsford, and Stoughton Dental/Wellness Centers and for mental health & substance abuse services from our TeamstersCare Mental Health & Substance Abuse professionals. (Note that you can have prescriptions filled, via mail order, from our Charlestown pharmacy.)

FImportant Note: For details on covered expenses and benefit levels under the Out of Area Option, you’ll need to read the TeamstersCare Tufts Out of Area Booklet, available from Charlestown Member Services.

About the TeamstersCare Tufts Out of Area Option

TeamstersCare provides your basic out of area medical coverage through Private Healthcare Systems® (PHCS), an association of medical providers with whom Tufts has contracted on our behalf.

The Teamsters Union 25 Health Services & Insurance Plan self-funds the benefits it provides through Tufts. Tufts provides members with medical benefits according to its contract with TeamstersCare and handles the administrative services needed to support the delivery of benefits.

To check for PHCS providers, call:

800-789-2078

or visit their website at www.phcs.com

For general Customer Relations, call:

888-679-0936

You can contact Tufts at:

Tufts Associated Health Plans, Inc.

600 Cordwainer Drive

Norwell MA 02061

Phone: 888-679-0936

Call Charlestown Member Services for an Out of Area Booklet and Provider Directory.
To determine if a provider or facility is in the Private Healthcare Systems® (PHCS) Network, call PHCS at 800-789-2078.

How the TeamstersCare Tufts Out of Area Option Works

Basically, the Out of Area Option provides the same types of general medical services as the HMO’s. So long as you use providers who participate in the PHCS provider network:

• services are generally covered at 100% after you make:

– a $15 copay for each office visit

– a $50 copay for each emergency room visit (waived if you are admitted to the hospital directly from the emergency room)

• you pay no coinsurance or deductibles

• you do not need any referrals to see specialists

• you file no claim forms for PHCS network services

If you use the services of a non-PHCS provider or facility, the Plan pays 80% of allowable reasonable and customary amounts, and you are responsible for the balance.

(“Reasonable and customary amounts” are the usual fees that healthcare providers charge for similar services in a given geographic area.)

Hospital Admissions

Emergency
TeamstersCare has one priority in cases of a serious emergency: you or your family member should get help as quickly as possible.

If you receive emergency services and are admitted as an inpatient, you (or someone acting on your behalf) must notify Tufts Health Plan within 48 hours of seeking care to be covered at the network level of benefits.

Non-Emergency
If you are going to be admitted to a PHCS network hospital, and it is not an emergency, you must call 1-800-789-2078 at least five days in advance to pre-register your admission. If you do not make this call, you may be subject to a pre-registration penalty.

Benefits the TeamstersCare Tufts Out of Area Option Does Not Cover

The TeamstersCare Out of Area Option has certain specific benefit limitations. For example, the Out of Area Option does not cover charges beyond specified coverage limits for services such as home health services and physical therapy. You’ll need to read the Out of Area Booklet for details.

FImportant Note: The Out of Area Option does not provide prescription drug, dental, vision, mental health & substance abuse, or hearing care services to TeamstersCare members. However, as a TeamstersCare Out of Area Option participant, these services are available to you and your dependents through our own dedicated TeamstersCare facilities or through other professional providers with whom we’ve contracted. See SECTION V, CLINICAL SERVICES BENEFIT.

When to Contact Tufts, PHCS, & Charlestown Member Services

In general, you should contact Tufts directly when you need information on:

• whether a particular healthcare service or procedure is a covered benefit

• the network professional staff, providers, and services

• questions related to claims, or coverage

• emergency procedures

In general, you should contact PHCS directly when you:

• need claims-related information

• want to confirm whether a provider is part of the PHCS network