HOW DO I OBTAIN VISION BENEFITS?
You may telephone VSP at (303) 426-9218 or 1-888-750-8276 to request a Vision Care Authorization Form. VSP will verify eligibility and issue the Authorization Form. After receiving the Authorization Form, you may make an appointment with a Network Provider and present the Authorization Form at the time of the appointment.
Instead of obtaining an Authorization Form, you may contact a Network Provider directly. However, if you do not present an Authorization Form or inform the Network Provider of your VSP coverage prior to receiving covered services, the provider is not obligated to accept VSP payment for these services.
A Network Provider will submit your claim to VSP and VSP will pay the provider directly.
If you receive services from a non-network vision provider, you must pay the provider and file a claim for reimbursement from VSP.
*These items apply to those employees who are covered for Dental and Vision benefits. Dental and Vision benefits are offered as optional coverage’s on an employer by employer basis.
WHERE DO I FILE MY DENTAL CLAIMS?
If you have the optional dental benefit, all dental claims are processed by Delta Dental Plan of Colorado; P.O. Box 173803, Denver, CO 80217-3803. Telephone (303) 741-9305 or 1-800-610-0201. The Group number for Hour Bank (plan B) Participant’s is 9772-1111 and for Monthly Contribution (Plan C) Participant’s is 9772-2222.
* These items apply to those employees who are covered for Dental and Vision benefits. Dental and Vision benefits are offered as optional coverage’s on an employer by employer basis.
IF MY ATTENDING PHYSICIAN IS A PARTICIPATING IN-NETWORK (PPO) PHYSICIAN, ARE ALL OTHER RELATED CHARGES FILED WITH THE PLAN COVERED UNDER THE PPO BENEFIT SCHEDULE, SUCH AS PATHOLOGY CHARGES, RADIOLOGY CHARGES, ANESTHESIA CHARGES, ETC.?
No. It is your responsibility to make sure each provider of service is a PPO provider. Each provider of services is considered separately. Example: If you have surgery scheduled with a PPO Physician, his/her charges are covered under the participating Physician contract. However, services for an assistant surgeon, Physician’s assistant, pathology, radiology, etc., are considered depending on whether or not each provider is a participating PPO provider.
CAN I COVER MY DEPENDENTS WHEN THEY CEASE TO BE ELIGIBLE FOR BENEFITS AS DEFINED BY THE PLAN?
Yes, temporarily. The Administrative Office must be notified within 60 days from the date the Dependent ceased to meet the definition of a Dependent. The Dependent may continue in the Plan for a limited time under COBRA continuation by making monthly self-payments of the total required premium.
ARE MY DEPENDENT CHILDREN COVERED AFTER AGE 26?
In qualifying cases after age 26, dependent children who are incapable of self-sustaining employment by reason of mental retardation or physical handicap and such incapacity commenced prior to the date the Dependent child’s coverage would have otherwise terminated under this Plan. Application for this coverage must be filed with the Administrative Office within 31 days after coverage would have otherwise terminated.
WHAT DO I DO IF I HAVE COVERAGE UNDER THIS PLAN AND ANOTHER PLAN (SUCH AS MEDICARE) FOR MYSELF AND/OR MY DEPENDENTS?
You must submit the claims to both this Plan and the other plan; we recommend that you file your claims with both plans at the same time. When your primary Plan has processed your claim and has provided you with their “Explanation of Benefits” (EOB), send a copy of their EOB to the Administrative Office where benefits payable from this Plan will be determined.
You must meet the timely claim filing requirements of this Plan. The Administrative Office must receive billings for medical services no later than one (1) year from the date services were rendered. If your other plan fails to provide you with an EOB by the timely claim filing limitation of this Plan and we have not received notification from you of these charges, benefits will not be payable by this Plan.
WHAT HAPPENS WHEN MY SPOUSE IS ALSO EMPLOYED?
You must provide the Administrative Office with the complete name and address of your spouse’s employer. In the event your spouse has other insurance coverage through his/her employer, the following will apply: Your spouse’s carrier is always the primary payer of your spouse’s claims.
If your spouse covers Dependent children, the Plan will determine who is the primary payer based on which parent’s birthdate falls earlier in the calendar year.
DO I HAVE TO COMPLETE A CLAIM FORM WITH EACH CLAIM FILED WITH THE ADMINISTRATIVE OFFICE?
You will not need to complete a claim form with each claim filed.
We only require a completed claim form once each calendar year; however, certain circumstances may arise which will require another completed claim form and you will be advised when this is needed.
WHAT IF I NEED MEDICAL CARE OUTSIDE OF THE STATE?
You are covered for medical services incurred anywhere in the world, subject to Plan benefits and exclusions and limitations.
DO I HAVE TO PRECERTIFY ALL MEDICAL CARE?
No. Only if you are going to be confined in a Hospital or facility as an inpatient or receive an outpatient MRI, CT scan, PET scan or outpatient surgery. Emergency admissions must be reported to HSAG 1-800-626-1577, within two working days after the admission. Failure to report such services will subject you to a $200 penalty. Note: all mental health and Substance Abuse treatment must be provided through and/or referred by the EAP (refer to page 69 of your Summary Plan Description).
Your doctor or the Hospital may contact HSAG, but it is ultimately YOUR RESPONSIBILITY to obtain timely precertification/authorization. You may contact HSAG by calling 1-800-626-1577.
HOW MUCH CAN I BE EXPECTED TO PAY OUT-OF-POCKET EACH YEAR?
Out-of-pocket maximums “cross accumulate” between the in-network and out-of-network Plans. If Preferred Providers are utilized, your out-of-pocket expense can be reduced. Please note, any charges that are not covered by the Plan are your responsibility in addition to the out-of-pocket expenses.
Please refer to page 28 of the Plan Summary Description to determine your specific out-of-pocket maximum.
WHAT IS A COPAYMENT?
A Copayment is a fixed dollar amount you are responsible for paying when you incur an Eligible Medical Plan expense for certain services. For information about copayments that apply to specific services, refer to your Schedule of Medical Benefits in your Summary Plan Description beginning on page 27.
If you are enrolled in a High-Deductible Plans (Trust 3000) once your deductible has been met you are not required to make an office copayment.
Please refer to page 27 of the Plan Summary Description for specific deductible information and page 30 for office visit copayment information.
WHAT CHARGES APPLY TO MY OUT-OF-NETWORK DEDUCTIBLE?
All out-of-network charges are subject to the calendar year deductible.
Out-of-Network routine preventative care services are NOT covered.
WHAT CHARGES APPLY TO MY IN-NETWORK DEDUCTIBLE?
Most medical Plan benefits are subject to the calendar year deductibles. Such charges include but are not limited to covered Hospital charges, therapy, medical supplies and prosthetic devices when prescribed at the direction of a Preferred Provider Physician (PPO) and most Non-Preferred Provider (Non-PPO) charges. Ancillary charges such as x-ray and laboratory must be billed by the same Physician providing the office visit services. Other services performed in the Physician’s office at the time of the office visit, such as minor surgical procedures, will be subject to the deductible. Ancillary services performed outside the Physician’s office or by any other provider will be subject to the deductible.
The deductible does not apply to routine preventative care, such as physical examinations, routine mammograms, prostate screening, routine nursery care of a newborn child, routine hearing care, and Physician office visit charges, including ancillary charges. For a complete description of covered preventative care go to: http://www.healthcare.gov/law/about/provisions/services/lists.html.
WHAT IS A DEDUCTIBLE?
Your deductible is the fixed amount of eligible medical Plan expenses during a calendar benefit period you are responsible for paying before the Plan begins to pay benefits. Plans have both individual and family deductibles established. Deductibles may vary between In-Network and Out-of-Network providers. If you have a question on your deductible amount, contact customer service at 303-428-5586 or 1-888-221-2201.
ARE PRESCRIPTION DRUGS COVERED?
Yes. Please refer to page 39 of your Summary Plan Description to determine specific copayments or deductible amounts that will be applicable to your prescription drugs.
HOW ARE NEW DEPENDENTS COVERED?
You must complete an enrollment card, adding your new Dependent (spouse, natural child, stepchild, legally adopted child or child for whom permanent custody is court ordered) under your coverage within 31 days of the date acquired. Please refer to pages 13-18 of your Summary Plan Description for Dependent coverage enrollment requirements, effective date of coverage and eligibility requirements. An enrollment card must be received by the Administrative Office within 31 days of marriage, birth, adoption or court order, otherwise your Dependent’s coverage will be delayed or may be subject to preexisting condition limitations.
Proof of dependency should be included with your enrollment card such as marriage records, birth certificates and court approved permanent custody documents or other applicable documents.
Please note: If the enrollment request is not received within 31 days, your dependents cannot be enrolled until Open Enrollment which occurs January 1 or each year.
