Select Benefits Insurance Information Booklet Addenda
Note: The following addenda are included in the most recent version of the Booklet – February, 2013.
- Page 2 — Who is Covered 7/1/01
- Page 3 — Dependent Eligiblity 7/1/11
- Page 6 — Changing Coverage 7/1/05
- Page 7 — Change in Status 7/1/01
- Page 11 — Benefit Summary Medical Benefits 7/1/12
- Page 12 — Prescription Drugs 7/1/03
- Page 14 — Vision Benefits 7/1/01
- Page 19 — Medical Plan Highlights 7/1/12
- Page 20 — Deductibles 7/1/12
- Page 23 — Covered Medical Expenses 3/1/11
- Page 26 — Hospitalization 4/1/10
- Page 31 — Outpatient Procedures & Plan Req'd Second Opinions 7/1/08
- Page 38 — Prescription Drugs - Exclusions 7/1/01
- Page 39 — Physical Examinations 7/1/12
- Page 40 — Newborn Care 7/1/08
- Page 42 — Travel 6/1/10
- Page 48 — Medical Treatment of Obesity 12/4/06
- Page 80 — If a Claim is Denied 7/1/11
- Page 81 — Continued Health Coverage ends 5/31/10
- Page 82 — Length of Continued Coverage 5/1/09
- Page 85 — Coordination of Benefits 7/1/03
- Page 90 — Free Choice of Hospital and Physician 4/1/10
- Page 95 —Highlights (HFSA) 7/1/12
- Page 96 —How the Plan Works (HFSA) 7/1/12
- Page 97 — Qualified health Care Expenses (HFSA) 1/1/11
- Page 100 — Claiming Your Reimbursements (HFSA) 5/1/11, 7/1/09
- Page 113 — Disability Benefits 7/1/01
Addendum to pages 2-3—Who is Covered
Effective 7/01/2001
Masters, Mates and Pilots
Not covered —covered by MM&P Trust
Correctional Officers
Covered under AlaskaCare
Addendum to pages 3-4—Dependents
Effective 7/1/2011 (Supersedes 1/1/2007 & 1/1/2010 addenda)
Provision of the Patient Protection and Affordable Health Care Act (PPACA)
Your eligible dependents for health insurance benefits include:
- Your spouse. You may be legally separated but not divorced.
- Same-sex partner as defined and documented by 2 AAC 38.010 - 2 AAC 38.100.
- Your children, including children of same-sex partner (as defined and documented by 2 AAC 38.010-2 AAC 38.100) from birth up to age 26, who are not eligible to enroll in any other employer-sponsored health plan.
- Your children age 26 and older who are incapable of employment because of a mental or physical incapacity. The incapacity must have existed before age 19 and the children must meet the definition of children:
- Your natural children, stepchildren, foster children placed through a State foster child program, legally adopted children, children in your physical custody and for whom bona fide adoption proceedings are underway, or children for whom you are the legal court appointed guardian;
- Unmarried and chiefly dependent upon you for support;
- You must provide the Claims Administrator with evidence the incapacity exists including proof: the incapacity existed before age 19 and of financial dependency. Children over age 26 are covered as long as the incapacity exists and periodic proof of the continued incapacity may be required.
Children that have access to their own employer group plan must enroll in that plan rather than their parent’s plan.
You must notify the Plan Administrator in writing within 60 days of the date your child no longer meets the eligibility criteria.
If you and your spouse/partner both work for the State, you may both be eligible for coverage as employees. You may also be covered as a dependent under these plans. Similarly, a child can be covered as a dependent of more than one employee.
Addendum to pages 6-7—Changing Coverage
Effective 7/01/2005
The dental and vision lock-in period has been changed from 24 months to 18 months.
Addendum to Page 7—Change in Status
Effective 7/01/2001
Changes in benefits (except HCRA) are allowed following a qualified status change. Life/AD&D/Survivor/Disability may always be changed following a qualified status change. However, changes in health or dependent care benefits must be consistent with the change in status.
Addendum to page 11—Benefit Summary Medical Benefits
Effective 7/1/2012
| Deductibles | Premium Plan | Standard Plan | Economy Plan |
|---|---|---|---|
| Annual Individual Deductible | $250 | $250 | $500 |
| Annual Family Deductible | $500 | $500 | $1000 |
Note: Deductible does not apply to preventive expenses – see page 45
| Coinsurance | Premium Plan | Standard Plan | Economy Plan |
|---|---|---|---|
| Most Medical Expenses | 90% | 80% | 70% |
| Most Medical Expenses after out-of-pocket limit | 100% | 100% | 100% |
| Preventive Expenses | 100% | 100% | 100% |
| Chemical dependency treatment | 90% | 80% | 70% |
| Mental/Nervous Treatment without Certification | 50% | 50% | 50% |
Out-of-Pocket Limit
After the deductible (except for preventive care which does not require a deductible), the plan pays the coinsurance shown above for most medical expenses until your portion reaches the out-of-pocket limit shown below. After that, the plan pays 100% of most covered services for the remainder of the benefit year for that person. Expenses that are paid at a coinsurance rate different than your normal coinsurance, such as mental/nervous disorder treatment without certification, are not credited to this out-of-pocket limit.
Addendum to page 12—Prescription Drugs
Effective 7/01/2003 (Supersedes 11/1/2001 addendum)
Effective July 1, 2003, the following copayments will apply:
Prescription Drugs
| Up to 30-Day Supply | 31 to 90-Day Supply | |
|---|---|---|
| All Drugs | 20% copay | 20% copay |
| Minimum | $8 copay | $16 copay |
| Maximum | $50 copay | $100 copay |
| 31 to 90-Day Supply | |
|---|---|
| Generic | $8 copay |
| Brand Name | $20 copay |
Annual Copay Maximum
- $1,000 Individual
- $2,000 Family
Prescriptions filled at a nonparticipating pharmacy or without the pharmacy card are subject to deductible and paid at 60%.
Prescription drug mail order forms are available from the pharmacy forms page.
Addendum to page 14—Vision Benefits
Effective 7/01/2001
Managed Care Vision has an increased frame allowance of $50 and now provides coverage for:
- Progressive lenses
- Antireflective coating
- Scratch resistant coating
- Polycarbonate lenses
Addendum to page 19 — Medical Plan Highlights
Effective 7/1/2012
Medical Plan Highlights
- Requires an annual deductible for each person, with a maximum annual deductible per family (excludes preventive care).
- Pays the coinsurance amount you select after the deductible for most covered expenses each year until your out-of-pocket expenses reach your out-of-pocket limit, then pays 100% of most covered expenses for that person for the remainder of the benefit year.
- Pays 100% of covered expenses for preventive care with no deductible
- Requires certification from the claims administrator for all inpatient stays, outpatient chemical dependency and mental disorder treatment, home health care, skilled nursing services, and certain outpatient procedures.
- Provides participating pharmacy card and mail-order programs for prescription drugs.
- Has an unlimited lifetime maximum benefit.
Addendum to page 20 — Deductibles
Effective 7/1/2012
Deductibles
The deductible amount is based on the plan you are enrolled in, Economy, Standard, or Premium, as shown in the Benefit Summary on page 13.
Each covered person must first meet the annual deductible, until your family reaches the family deductible limit, before the medical plan begins to pay benefits. Preventive expenses as described on page 45 are not subject to the deductible.
In the event of a common accident involving two or more family members, only one deductible is required.
Addendum to page 23 — Covered Medical Expenses
Effective 3/01/2011
The medical plan provides extensive and valuable benefits for you and your eligible dependents. Benefits are available for medically necessary services and supplies necessary to diagnose, care for, or treat a physical or medical condition. Any portion of a claim which is itemized as sales, excise or other taxes is not reimbursable.
Addendum to page 26—Hospitalization
Effective 4/01/2010 (Supersedes 7/01/2004 addendum)
There is a hospital-only preferred provider agreement in effect for hospital services in the municipality of Anchorage, and in the remaining 49 states. This plan does not include services provided by hospitals outside of Anchorage while still in Alaska. The preferred provider in Anchorage is Alaska Regional Hospital.
The plan will reduce benefits by 20 percent if a member receives services from a nonpreferred hospital. In addition, the out-of-pocket maximum that otherwise applies under your Plan will be doubled. All services provided by a hospital, including testing or outpatient surgery, are subject to this provision except for:
- Services received when following a referral from the managed behavioral health administrator for mental health/chemical dependency treatment,
- Services that can not be performed at the preferred Anchorage area hospital, or
- Services received for emergency treatment defined by the plan as follows:
A medical emergency is the sudden and unexpected onset of a condition or an injury--including severe pain--such that a prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the person’s health, or with respect to a pregnant woman, the health of the woman and her unborn child. There are many conditions that may determine medical emergencies--what they all have in common is the need for quick action.
Coordination of benefits will be provided without penalty for dependents whose primary insurance participates with a nonpreferred provider.
Addendum to page 31—Outpatient Procedures and Plan-Required Second Opinions
Effective 7/01/2008
All listed procedures requiring pre-certification have been removed except for the following:
- MRI-knee
- MRI-spine
Addendum to page 38—Prescription Drugs - Exclusions
Effective 7/01/2001
The plan covers birth control drugs or devices that require a doctor’s prescription.
Addendum to page 39 — Physical Examinations
Effective 7/1/2012 (supersedes 7/1/2011 addendum)
The plan covers, at 100% of the recognized charge with no deductible, one routine physical examination for each covered person per benefit year, including physician’s services and one of each related X-rays, laboratory services and screening/diagnostic tests prescribed by the physician even if provided separately from the examination. This benefit does not cover exams connected with illness or accident, required for employment or to obtain insurance.
Addendum to page 40—Newborn Care
Effective 7/01/2008
Well Baby Care
Effective July 1, 2008, the Select Benefits active employee AlaskaCare health plan will cover outpatient routine examinations and screenings, including immunizations, for dependents from birth through 24 months of age according to the current American Association of Pediatrics (AAP) published guidelines in effect on the date of service. Coverage is 100% of the recognized charge, without deductible being assessed for these services.
Addendum to page 42—Travel
Effective 6/01/2010
Travel is revised as follows:
- round-trip transportaion, not exceeding the cost of coach class commercial air transportation, from the site of the illness or injury to the nearest professional treatment. If you use ground transportation and the most direct one-way distance exceeds 100 miles, the medical plan pays your documented travel expenses while en route for fares, mileage, food and lodging for the most direct route. Only eligible persons are reimbursed.
Addendum to pages 48-49—Medical Treatment of Obesity
Effective 12/04/2006 (Supersedes 10/2006 addendum)
Medical Treatment of Obesity
Medically necessary expenses for medical treatment of obesity will be covered as any other medical condition when the following criteria are met.
- Body Mass Index (BMI) greater than or equal to 30kg/m2, or
- BMI greater than or equal to 27kg/m2 with underlying comorbidities, including but not limited to, cardiopulmonary complications, diabetes, hypertension and obstructive sleep apnea.
Noncovered services currently listed on page 50 are revised to include, but is not limited to:
- Special diet supplements, vitamin injections, hospital confinement for weight reduction programs, exercise club membership fees, exercise equipment, whole body calorimeter studies, biofeedback and hypnosis.
Surgical Treatment of Obesity
Medically necessary expenses for surgical treatment of obesity will be covered as any other medical condition when the following criteria are met.
- Body Mass Index (BMI) greater than or equal to 40kg/m2 or BMI greater than or equal to 35kg/m2 with underlying comorbidities, including but not limited to, cardiopulmonary complications, diabetes, hypertension and obstructive sleep apnea; and
- Completion of bone growth; and
- Drug/alcohol screen with either no drug/alcohol abuse by history or alcohol and drug free period for greater than or equal to one year; and
- Continued obesity despite medically supervised weight loss treatment for at least six months cumulatively, during the two years prior to surgery, or
- Documentation in the medical record of the member’s participation in a multidisciplinary surgical preparatory regimen of at least three months duration, completed prior to the time of surgery, meeting all of the following criteria:
- Consultation with a dietician or nutritionist; and
- Reduced calorie diet program supervised by a dietician or nutritionist; and
- Exercise regimen (unless contraindicated) to improve pulmonary reserve prior to the surgery, supervised by exercise therapist or other qualified professional; and
- behavior modification program supervised by qualified professional; and
- Documentation in the medical record of the member’s participation in the multidisciplinary surgical preparatory regimen
Noncovered services currently listed on page 58 are revised to include, but is not limited to:
- Special diet supplements, vitamin injections, hospital confinement for weight reduction programs, exercise club membership fees, exercise equipment, whole body calorimeter studies, biofeedback and hypnosis.
Covered surgical obesity procedures are limited to:
- Lap Band Gastric Banding, Roux-en Y Gastric Bypass and Vertical Banded Gastroplasty when all selection criteria are met.
Addendum to page 80 — If a Claim is Denied
Effective 7/01/2011
If a claim or precertification is denied, in whole or in part, your Explanation of Benefits (EOB) or letter from the Claims Administrator will explain the reason for the denial. If you feel your claim or precertification should be covered under the terms of this plan, you should contact the Claims Administrator to discuss the reason for the denial. If you still feel the claim or precertification denial should be covered under the terms of the Plan, you can take the following steps to file an appeal.
Claims Administrator Appeals
- Level I Appeal
- Submit your request in writing, explaining the nature of your appeal, including copies of EOB’s, correspondence, and pertinent medical records. Your appeal must be received by the Claims Administrator within 180 days of the date the EOB or precertification denial letter was issued. You will receive a written decision from the Claims Administrator within 30 days after their receipt of your appeal. If you are not satisfied with the Level I decision, you can submit a Level II appeal review.
- Level II Appeal
- The Claims Administrator must receive your written request for a Level II appeal within 60 days of the date the Level I decision letter was issued. Your appeal will be reviewed by a panel who did not participate in the Level I review. You will receive a written decision from the Claims Administrator within 60 days after their receipt of all relevant information in your appeal. If you are not satisfied with their final decision, you can request a review by the Plan Administrator.
- Plan Administrator Appeals
- If you disagree with the final Claims Administrator’s decision, you can send a written request for review to the Plan Administrator. Your appeal must be postmarked or received within 45 days from the date the Claims Administrator’s final decision letter was issued. The Plan Administrator will request a copy of your Claims Administrator appeal file, including any documentation from your provider for their records and review of your appeal. You may submit additional relevant material with your written appeal. The Plan Administrator will issue a decision within 90 days after receiving all the relevant material in your appeal.
- Your appeal may be sent to an Independent Review Organization (IRO). IRO is an organization of medical experts qualified to review your appeal. If your appeal is forwarded to the IRO, the Plan Administrator will issue a decision in writing within 30 days after receiving the IRO’s recommendation. If you are not satisfied with the decision, you may appeal to the Superior Court.
- Urgent Appeals
- If your doctor or provider advises the Claims Administrator or Plan Administrator that a delay in your appeal process could harm your health, an emergency review and decision will be made within 72 hours after receipt of your appeal.
Addendum to page 81—Continued Health Coverage
Effective 9/01/2008 - 5/31/2010 (Supersedes 9/01/2008 - 12/31/2009 addendum)
The American Recovery and Reinvestment Act of 2009 (ARRA) provides for a 65% reduction in COBRA premiums for certain assistance eligible individuals (AEI’s) for up to 9 months. An assistance eligible individual is a COBRA “qualified beneficiary” who meets all of the following requirements: he or she;
- Is eligible for COBRA continuation coverage due to an involuntary termination at any time during the period beginning September 1, 2008, and ending May 31, 2010 (or the date provided by federal law, if extended);
- Elects COBRA coverage when first offered or during the special election period;
- Has a qualifying event for COBRA coverage that is the employee’s involuntary termination (except for gross misconduct) during the period beginning September 1, 2008, and ending May 31, 2010 (or the date provided by federal law, if extended) and,
- Has paid 35% of the premium for the COBRA coverage elected.
Details on this special program, including special election rights you may have, will be mailed to all COBRA qualified beneficiaries. Please contact the Division or your Personnel Service Center if you have any questions about whether or not you qualify for the subsidy.
Addendum to page 82—Length of Continued Coverage
Effective 5/01/2009
This replaces the information in the Select Benefits Insurance Information Booklet on pages 96-97.
If you lose health coverage because you have begun leave without pay, been laid off, or terminate your employment (for other than gross misconduct), you may continue coverage for up to 18 months.
If your dependent loses health coverage due to divorce, your death or they no longer meet the eligibility criteria, they may continue coverage for up to 36 months. If your dependents have more than one qualifying event, they may be eligible for an additional period of coverage but the combined periods cannot exceed 36 months.
If you or your dependents are disabled when coverage continuation begins you may continue coverage for up to an additional 11 months. To elect this additional coverage you must notify the division of your status before the end of your 18-month coverage period and within 60 days of your Social Security disability determination. The premium may increase for the additional 11 months of coverage. Coverage may be terminated if Social Security determines you are no longer disabled. In this case, you must notify the division within 30 days of the final Social Security determination.
Addendum to pages 85-86—Coordination of Benefits
Effective 7/01/2003
Coordination between State employee health plans
Select Benefits has new rules effective July 1, 2003, for members who have other coverage through a state employee health trust.
Select Benefits will only pay 30% of covered charges for your dependents if your spouse or children are covered by a state employee health trust and that coverage:
- has been waived,
- pays less than 70% of covered expenses, or
- has an individual out-of-pocket maximum, including deductible, of more than $3,500.
Addendum to page 90—Free Choice of Hospital and Physician
Effective 4/01/2010 (Supersedes 7/01/2004 addendum)
There is a hospital-only preferred provider agreement in effect for hospital services in the municipality of Anchorage, and in the remaining 49 states. This plan does not include services provided by hospitals outside of Anchorage while still in Alaska. The preferred provider in Anchorage is Alaska Regional Hospital.
The plan will reduce benefits by 20 percent if a member receives services from a nonpreferred hospital. In addition, the out-of-pocket maximum that otherwise applies under your Plan will be doubled. All services provided by a hospital, including testing or outpatient surgery, are subject to this provision except for:
- Services received when following a referral from the managed behavioral health administrator for mental health/chemical dependency treatment,
- Services that can not be performed at the preferred Anchorage area hospital, or
- Services received for emergency treatment defined by the plan.
Coordination of benefits will be provided without penalty for dependents whose primary insurance participates with a nonpreferred provider.
Addendum to page 95—Highlights (HFSA)
Effective 7/1/2012
Health Care Reimbursement Account Highlights
- Reimburses you for many expenses not otherwise covered by the health plan.
- Contributions are not subject to federal taxes.
- May contribute up to $208 each month
- Use it or lose it. Any balance remaining in your account at the end of the benefit year is forfeited.
Addendum to page 96—How the Plan Works (HFSA)
Effective 7/1/2012
Coverage begins and ends as specified on pages 10 and 11. You decide how much you want to contribute each month, up to a maximum of $208 per month. Your contribution must be:
- in whole dollars,
- at least $20 per month ($120 per year), and
- no more than $208 per month.
Addendum to pages 97-99—Qualified Health Care Expenses
Effective 1/01/2011 (Supersedes 3/01/2004 addendum)
Health Care Reimbursement Account (HCRA) is changed to Health Flexible Spending Account (HFSA)
Qualified Health Care Expenses
Eligible expenses must meet the Internal Revenue Service definition under IRC 213(d) for medical expenses and must not be covered or paid in full by your health plan(s). The final determination for eligibility is made by the Plan.
A complete list of tax deductible medical expenses is available in IRS publication #502.
Most eligible services or supplies must be prescribed and/or performed by a licensed provider. Only those expenses which are not paid by any of your health plans are eligible to be reimbursed.
Over-The-Counter Drugs
Effective January 1, 2011, OTC drugs and medicines may be reimbursed from your HFSA only if the claim is accompanied by a written prescription from a healthcare provider who is licensed to prescribe drugs.
Certain items are exempt from this requirement including:
- Insulin
- Co-pays and deductibles
- Items that are not drugs or medicines
- Medical equipment such as crutches
- Medical supplies such as bandages
- Diagnostic devices such as blood sugar test kits
Please note that certain items such as homeopathic medicines or vitamins require a certificate of need or similar documentation. A list of these items, and those covered under the OTC provision, is included on the HFSA OTC claim form.
Note: Cosmetic surgery or procedures (such as tooth bleaching) and insurance premiums are not eligible expenses.
Addendum to page 100 — Claiming your Reimbursements (HFSA)
Effective 5/01/2011
Claims for services incurred during the benefit year will be accepted any time during that year. You have a 90-day grace period (until September 30) to file all unpaid claims for that benefit year.
Effective 7/01/2009
Over-The-Counter (OTC) claims submission—with this option, you submit claims to the HFSA claims administrator regardless of whether you have selected streamlined or direct claims submission. You must submit each claim with itemized statements or receipts, an explanation of benefits form (EOB) from all health plans, and the prescription or certificate of need.
Addendum to pages 113-118—Disability Benefits
Effective 7/01/2001
AlaskaCare Disability Plan Changes
Short-term Disability (pages 113 & 117)
- Increase weekly benefit to $210
- Increase length of payment to 180 days from disability date
Long-Term Disability (pages 113, 117-118)
- Increase waiting period to 180 days
- Maximum benefit $8,000 per month
Pre-existing Conditions (page 114 )
- Preexisting changed to not cover disability occurring in first 24 months of coverage due to a preexisting condition. Preexisting conditions are those that existed during 12 months before coverage was effective.