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Health FAQ
- When and how do I become eligible for coverage?
You become eligible for coverage the first day of the third month following two consecutive months in which you fulfilled the initial eligibility hours requirement. For Shop Employees, this is 250 hours reported and paid into your reserve account. For Installers, this is 170 hours reported and paid into your reserve account. Eligibility is determined using an advanced eligibility system. For example, if you worked the initial eligibility hours required in March and April, and these hours were reported and paid for by your employer in April and May, your eligibility would begin in July.
- Once I am eligible, how long will I be covered?
You will be covered so long as the hours reported and paid in by your employer each month total at least 125 if you are a Shop Employee and 85 if you are an Installer. As an example of how advanced eligibility system operates, hours worked in May would be reported and paid in June; these hours would provide your coverage in August.
- How does my reserve account work?
Hours are reported and paid in by your employer following the month in which they were worked. As stated above, you need to work a minimum of 125 hours in the work month as a Shop Employee, and a minimum 85 hours in a work month as an Installer, to be eligible in the coverage month. The coverage month begins the first of the second month following the income month. Any hours in excess of the monthly requirement are placed into your reserve account. If, in a month, you have fewer than the minimum required hours reported, you can use any hours in your reserve account to make up the difference.
- Is there a limit to the number of hours that I can have in my reserve account?
Yes. For Shop Employees, the maximum number of hours that you can have in your reserve account is 500. For Installers, the maximum number is 340.
- What are my coverage plan options?
For medical coverage, you have a choice between two plans: a self-funded PPO plan or the Kaiser HMO. The dental plan is also self-funded, and vision benefits are provided through Vision Service Plan.
- What is a PPO plan?
With a PPO plan, you can select and visit any medical provider. Your out-of-pocket costs will be lower if you visit a PPO provider. These are providers who are contracted with the Anthem Blue Cross Prudent Buyer Network.
- What is Utilization Review?
The self-funded PPO Plan requires Utilization Review (UR) for certain services including all hospital admissions and overnight stays at any medical facilities. The UR provider is Anthem Blue Cross. The UR provider performs preadmission review, concurrent review and discharge planning to ensure that all inpatient care is medically necessary. Charges that Anthem Blue Cross determines to not be medically necessary will not be covered, and no benefits will be paid for such charges.
- Who contacts the UR Provider?
It is your responsibility to either contact Anthem Blue Cross directly or to make sure that your physician contacts them at (800) 274-7767. Failure to notify Anthem Blue Cross as required will result in a decrease in benefits paid of at least 50%,
- Which plan is better?
Both plans are excellent. You should carefully study the comparisons to determine which plan would suit you and your family best. The PPO plan allows you to visit providers of your choice. The Kaiser Plan requires all services to be obtained at Kaiser facilities with Kaiser’s practitioners.
- Does my plan have chiropractic/specialist coverage?
Yes. Please refer to your Summary Plan Description for details.
- How do I enroll in my chosen plans?
To ensure that you and your dependents are covered in the Sign plan, you must complete the Enrollment Form that is sent to you by Allied Administrators when you first become eligible for coverage. If you wish to enroll in Kaiser, you must also complete a Kaiser Enrollment/Change Form.
- How do I add or delete dependents on my health plans?
You can add or delete a dependent by printing and completing an Add/Delete Dependents Form and mailing it to Allied Administrators. Please read the form carefully, as you are required to submit the appropriate documentation, i.e., birth or marriage certificate, divorce decree, etc. If you prefer, you can also contact Allied directly for this form. If you are enrolled in Kaiser and wish to add or delete a dependent, you must also complete the Kaiser Enrollment/Change Form.
- My child has reached the limiting age, but he is completely dependent on me for support due to a physical limitation. Is there a way I can extend his coverage?
Yes. If you have a dependent child with a mental or physical limitation, you can continue his coverage provided that the following requirements are met: your child is completely dependent on you for support; your child is not capable of self-sustaining employment; and you give us proof of the child’s handicap: (1) not later than 31 days after the child attains the limiting age; and (2) thereafter as the Trustees may require, but not more than once every two years, by completing a Request for Continued Coverage for Incapacitated Child form.
- How/when can I change plans?
The Plan conducts an annual open enrollment. During this open enrollment period, you will have the opportunity to change your medical plan, if you wish. You will be notified by Allied Administrators when the open enrollment period begins.
- How do I file a claim for reimbursement?
You’ll need to fill out a Claim Form. Be sure to complete all sections and attach appropriate documentation. Then, submit the form to Allied Administrators for reimbursement. You can also contact Allied directly for a claims form.
- Is it possible for my physician to submit claims to Allied Administrators electronically?
Yes! If your physician’s office is set up for electronic filing, simply provide Allied’s EDI number: 94177. That’s all the information they’ll need to file claims electronically.
- How will I know if a claim has been paid?
Allied will send you an Explanation of Benefits (EOB) statement whenever a claim has been paid on your behalf. If you utilize PPO providers, Allied will send payment directly to the PPO provider and a copy of the EOB to you that shows all the charge and payment information regarding the claim.
- Can you explain how I should read the EOB?
A sample EOB can be found here. Reading from left to right, top to bottom, the first section displays the health plan name, your masked identification number, and the number assigned to the claim.
Next, you’ll see the employee’s name, the patient’s name, the claims examiner, group number and date the claim was processed.
The next section covers the date(s) of treatment, the three-letter service code and the five-digit Current Procedure Terminology (CPT) code used by the billing provider of service. It also shows how the claim was adjudicated. In our sample EOB, there were two procedures (treatments) on the same day. The Charge Amount column shows what the provider has billed for these procedures. The next column shows if any charges were not covered. In this example, there were charges not covered, and the two-digit reason code is shown next. The PPO Discount is then applied, and the column after that shows the Covered Amount (Charge Amount – Not Covered – PPO Discount). The deductible and any co-pays are then applied. In this example, the calendar year deductible has already been met, and there are no co-pays. The next column in the EOB shows the percentage that the Plan pays. Because this was a PPO provider, the percentage is 90%. Finally, there is the Payment Amount, the amount that will be paid to the provider.
Immediately under this section, is an area containing the patient account number from the doctor’s office (if it is available) and any adjustments or credits made in the event there is other coverage.
The next item is the Patient’s Responsibility section. It is the combination of Amount not Covered, Co-Pay Amount, Deductible and Co-Insurance. This would be the amount that you would have to pay your provider.
The Payment Information box shows who the plan payment was sent to, the date it was sent, check number and amount paid.
The Service Code box defines the three-letter code used on the lines above. The Reason Code box provides an explanation of the two-digit code for why charges were not covered. Finally, the Messages box shows which PPO network was utilized, if any, and your appeal rights.
- Can my provider bill me for the PPO discount?
If you visit a provider who is contracted with the PPO, the provider cannot bill you for anymore than the amount shown under Patient’s Responsibility on the EOB. Billing for any amount greater than that is known as “balance billing,” and this practice is prohibited by California state law.
- I need to see a Doctor, but I don't know who to go to. Do you have a list of doctors near where I live or work?
Absolutely. If you are in the PPO plan, you can get a list of providers close to you at the Anthem Blue Cross Prudent Buyer website. Kaiser participants can obtain information on providers at www.kaiserpermanente.org.
- I need to fill my prescriptions – what pharmacy can I use?
If you are in the self-funded PPO, you can use any of the hundreds of pharmacies that are contracted with Sav-Rx, the PPO plan’s pharmacy benefits manager. Visit their website at www.savrx.com for a listing of pharmacies in your area. Kaiser participants must have their prescriptions filled at Kaiser pharmacies.
- I tried to pick up my prescription but the pharmacy told me that I need “prior authorization.” What should I do?
Certain prescriptions require prior authorization from the health plan in which you are enrolled. If you are covered by the self-funded Plan with Sav-Rx, your pharmacist will let you know if a prescription needs prior authorization. Most pharmacies will work directly with Sav-Rx and your doctor’s office. If this is not the case, your physician‘s office should get in touch with the help desk at Sav-Rx (1-800-228-3108) or contact Allied Administrators.
- Do I need an ID card for medical and dental?
If you are in the self-funded PPO plan and visit a provider who is in the Anthem Blue Cross Prudent Buyer Network, you do need to bring your Anthem Blue Cross PPO card to your medical appointment. Kaiser participants have ID’s that are issued directly by Kaiser. These must be used for all medical appointments. For appointments with dental PPO providers, you must bring your Anthem Blue Cross Dental ID card.
- Does the dental plan have a PPO?
Yes, the dental plan utilizes the Anthem Blue Cross Dental Preferred Provider Organization. You can visit any provider. The PPO dentists, however, have agreed not to charge over a certain amount for different dental procedures, which means your dental benefits will go farther when you visit a PPO dentist.
- Is there a claim form specifically for dental claims?
There is a Dental Claim Form, which you can bring with you to your dental appointment. Your dentist can also utilize electronic filing. Simply give your dentist's office Allied's EDI number: 94177.
- I went to my doctor’s appointment today, but I was told that my coverage is terminated. I've been working steadily. Am I covered for the visit?
If there’s ever a question regarding your eligibility, contact Allied Administrators. We’re here to help you sort it out.
- I received a COBRA/Termination letter. Why did I get this notice and what do I need to do?
You received this notice because you had a COBRA Qualifying Event. The most common reason for this is the combination of current hours worked and the hours in your reserve account was less than 125 hours if you are a Shop Employee, or less than 85 hours if you are an Installer. Other COBRA Qualifying Events include a dependent child's reaching the maximum age limit, divorce, or death of the participant. In each of these instances, you will have lost eligibility. If you wish to sign up for COBRA coverage, you must return the application to Allied Administrators within 60 days of the date of your Qualifying Event.
- What is the self-pay coverage option I’ve been hearing about?
If the combination of current hours and hours in your reserve account do not satisfy the monthly eligibility requirement, you may be eligible to make a self-payment to maintain your coverage. The self-payment amount required is a flat amount set from time to time by the Board of Trustees. You must work a certain number of hours in order to be eligible for self-pay coverage. If you are a Shop Employee you must work a minimum of 90 hours in a month. For Installers, you must work a minimum of 60 hours in a month. Self-payments must be made by the 20th of the month prior to the coverage month. For example, Allied must receive your self-payment in June to allow your coverage in July. You can check your hours on this site to determine if you would need to make a self-payment to continue coverage. So, for this example, the work month is April, and your hours would be reported in May. At the beginning of June, you’d be able to determine if you had enough hours for coverage in July. If you don’t have enough hours but did work the minimum hours in April to qualify for this benefit. you would print the Self-Payment Remittance Form and return it with your payment by June 20th.
- I'm on disability/worker's comp or FMLA. How do I continue my coverage?
The Trust offers disability coverage at no cost to the member for a specified duration. You should contact Allied Administrators for more information. When your period of disability coverage has ended, you can elect to take COBRA coverage. FMLA coverage is through your employer only, and you must contact your employer to determine what steps you need to take.
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