Benefits - Medical

Benefits - Medical Anonymous (not verified) August 18, 2015

COBRA

COBRA

Consolidated Omnibus Budget Reconciliation Act

In compliance with the federal law COBRA, the College offers full-time faculty and staff continuation of the medical benefits coverage. If you lose coverage due to termination or reduction in hours, you will be offered COBRA coverage for 18 months. An additional 11 months, for a total of 29 months, can be given to a qualified beneficiary who is determined to be disabled by the Social Security Administration at the time of the qualifying event or if the qualified beneficiary becomes disabled during the first 60 days of COBRA coverage. If an enrolled dependent loses coverage due to death of the covered employee, divorce, or legal separation of the employee or a child reaches the age limit for the Plan, the dependent will be offered continuation coverage for 36 months.

It is the employee’s responsibility to notify the College of a divorce, legal separation, or a child reaching the age limit within 60 days of the later of the date of the event or the date on which coverage would be lost because of the event.

Individuals who elect to continue the medical benefits coverage will be required to pay 100% of the total premium plus an administration fee.

HealthSmart will send a notice to the home address on file when an employee is eligible for coverage. You may contact the Benefits Services Manager for additional information.

After the 18-month, 29-month, or 36-month period, medical benefits coverage will be terminated.

 

Anonymous (not verified) August 18, 2015

Claims

Claims

How to Submit a Claim. When a Covered Person has a claim to submit for payment, that person must:

  1. Obtain a claim form from the Human Resources Office or the Plan Administrator.
  2. Complete the Employee portion of the form. All questions must be answered.
  3. Have the Physician complete the provider’s portion of the form.
  4. For Plan reimbursements, attach bills for services rendered. All bills must show:
    • Name of Plan
    • Group number of Plan
    • Employee’s name
    • Name of patient
    • Name, address, telephone number of the provider of care
    • Diagnosis
    • Type of services rendered, with diagnosis and/or procedure codes
    • Date of services
  5.  Send the above to the Claims Administrator at this address:
    HealthSmart
    P.O. Box 111047
    Memphis, TN 38111
    (901) 473-3100

When Claims Should Be Filed: Claims should be filed with the Claims Administrator within 90 days of the date charges for the service was incurred. Benefits are based on the Plan’s provisions at the time the charges were incurred. Charges are considered incurred when a treatment or care is given or a procedure performed. Claims filed later than that date may be declined or reduced unless:

  • it is not reasonably possible to submit the claim in that time; and 
  • the claim is submitted within one year from the date incurred. This one-year period will not apply when the person is not legally capable of submitting the claim.

The Claims Administrator will determine if enough information has been submitted to enable proper consideration of the claim. If not, more information may be requested from the claimant. The Plan reserves the right to have a Plan Participant seek a second medical opinion.

A request for Plan benefits will be considered a claim for Plan benefits, and it will be subject to a full and fair review. If a claim is wholly or partially denied, or if there is any other adverse benefit determination, the Claims Administrator will furnish the Plan Participant with a written notice. The written notice will contain the following information, in addition to any other information required by law:

  • the specific reason or reasons for the adverse benefit determination; 
  • specific reference to those Plan provisions on which the determination is based; 
  • a description of any additional information or material necessary to correct the claim and an explanation of why such material or information is necessary; and 
  • appropriate information as to the steps to be taken if a Plan Participant wishes to submit the claim for review.

A Plan Participant will be notified as to the acceptance or denial of a claim within the following time frames:

  • Urgent care claims: Within 72 hours of receipt of the claim, unless the Plan Participant fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the Plan. In the case of such failure, the Plan Administrator will notify the Plan Participant of the specific information necessary to complete the claim within 24 hours after receipt of the claim by the Plan. The Plan Participant will then have at least 48 hours to provide the specified information. The Plan Administrator will then notify the Plan Participant of the acceptance or denial of the claim within 48 hours of the earlier of the Plan Administrator’s receipt of the specified information or the end of the period afforded the Plan Participant to provide the specified information
  • Pre-service claims: Within 15 days of the Plan’s receipt of the claim.
  • Post-service claims: Within 30 days of the Plan’s receipt of the claim.

If special circumstances require an extension of time for processing a non-urgent care claim, the Claims Administrator shall send written notice of the extension to the Plan Participant. The extension notice will indicate the special circumstances requiring the extension of time and the date by which the Plan expects to render the final decision on the claim. In no event will the extension exceed a period of 15 days from the end of the initial 15-day period for pre-service claims, or a period of 30 days from the end of the initial 30-day period for post-service claims.  If the extension is necessary due to the Plan Participant’s failure to submit the information necessary to decide the claim, the extension notice shall specifically describe the required information, and the Plan Participant will have at least 45 days from receipt of the notice to provide the specified information.

If a Plan Participant is not notified as to acceptance or denial of a claim within the time frames provided above, the claim shall be deemed denied. Note-Failing to respond to the claim within these time periods can have adverse effects on Rhodes.  The participant will be free to sue for benefits (rather than follow the administrative appeal process), and the court will be able to review the denial de novo (the standard is typically abuse of discretion when the plan follows the procedural requirements).

Claims Review Procedure: In cases where a claim for benefits payment is denied in whole or in part, or if there is any other adverse benefit determination, the Plan Participant may appeal the denial. This appeal provision will allow the Plan Participant to:

  1. Request from the Plan Administrator a review of any claim for benefits. Such request must include: the name of the Employee, his or her Social Security number, the name of the patient and the Group Identification Number, if any. 
  2. File the request for review in writing, stating in clear and concise terms the reason or reasons for this disagreement with the handling of the claim. 
    The request for review must be directed to the Plan Administrator or Claims Administrator within 180 days after the claim payment date or the date receipt of the notification of denial of benefits.

A review of the denial or other adverse benefit determination will be made by the Plan Administrator and the Plan Administrator will provide the Plan Participant with a written response as follows:

  • Urgent care claims: Within 72 hours of receipt of the Plan Participant’s request for the review of the adverse benefit determination.
  • Pre-service claims: Within 30 days of the Plan Participant’s request for review of the adverse benefit determination.
  • Post-service claims: Within 60 days of the Plan Participant’s request for review of the adverse benefit determination.

If the Plan Participant is not notified of the plan’s decision within the time frames provided above, the Plan Participant may deem the claim denied. As noted above, failing to respond to the claim within these time periods will permit a reviewing court to review the denial de novo, rather than abuse of discretion.

The Plan Administrator’s written response to the Plan Participant shall cite the specific reason or reasons for adverse determination, the specific Plan provision(s) upon which the determination is based, and any other information required by law.

A Plan Participant must exhaust the claims appeal procedure before filing a suit for benefits.

For further information, please see a copy of the Summary Plan Description of the Welfare Benefit Plan.

Note: The Rhodes College Handbook is not a contract of employment, nor should it be construed to create a contract with the College. Rhodes reserves the right to make future changes to its policies, practices, and fringe benefits. If such changes occur, the College will inform employees of such changes and their effect, if any. If you have questions, please contact The Rhodes Human Resources Department at hr@rhodes.edu.

Anonymous (not verified) August 18, 2015

Dental Insurance

Dental Insurance

Voluntary Dental Insurance

Plan Sponsor. This Plan is sponsored by Rhodes College, 2000 North Parkway, Memphis, TN 38112.

Eligible Participants. All full-time faculty and staff have the option to purchase dental insurance coverage for themselves, their domestic partner and their dependents.

Date Eligible for Coverage. Each employee becomes eligible for dental coverage under the Plan the first day of the month following the date of employment with Rhodes.

Date Eligible for Dependent Coverage. A dependent shall become eligible for coverage on either (a) the first day that the employee becomes eligible for coverage and satisfies the definition of eligible dependent coverage or (b) the day a covered employee first acquires an eligible dependent.

Benefits Provided. There are two separate Dental Plans available.

Split Value Plan In-Network

  • $100 lifetime deductible per covered individual (maximum 3 per family)
  • Diagnostic and preventive services covered at 100%
  • Basic services covered at 80% after deductible has been met
  • Major services covered at 50% after deductible has been met
  • $1,000 per person maximum benefit per calendar year

Split Value Plan Out-of-Network

  • $100 lifetime deductible per covered individual (maximum 3 per family)
  • Diagnostic and preventive services covered at 100% of the network rate after the deductible has been met
  • Basic services covered at 50% after the deductible has been met
  • Major services covered at 25% after the deductible has been met
  • $1,000 per person maximum benefit per calendar year

PPO Plan In-Network

  • $100 lifetime deductible per covered individual (maximum 3 per family)
  • Diagnostic and preventive services covered at 100%
  • Basic services covered at 100% after deductible has been met
  • Major services covered at 60% after deductible has been met
  • $2,000 per person maximum benefit per calendar year

PPO Plan Out-of-Network

  • $100 lifetime deductible per covered individual (maximum 3 per family)
  • Diagnostic and preventive services covered at 100% after the deductible has been met
  • Basic services covered at 80% after deductible has been met
  • Major services covered at 50% after deductible has been met
  • $1,500 per person maximum benefit per calendar year

There is a monthly charge for dental insurance coverage that is paid through payroll deduction. At the employee’s option, dental insurance premium payments may be deducted through the flexible benefits program (pre-tax option).

Currently the insurance company is Guardian Life Insurance Company. Request for information concerning Guardian Life Insurance Company contract terms, condition and interpretation thereof, claims thereunder, any requests for review of such claims and service of legal process may be directed in writing to: Guardian Life, 7 Hanover Square, H-26-E, New York, NY 10004.

The requirements for being covered under this Plan, the provision concerning termination of coverage, a description of Plan benefits (including any limitations and exclusions which may result in reduction or loss of benefits) are explained in the Certificate of Coverage.

Guardian Life offers a Vision discount plan to participants covered under the dental plan and their dependents. For additional information, please contact the Benefits Services Manager.

The plan year is July through June.
For a statement of ERISA rights see ERISA

Note: The Rhodes College Handbook is not a contract of employment, nor should it be construed to create a contract with the College. Rhodes reserves the right to make future changes to its policies, practices, and fringe benefits. If such changes occur, the College will inform employees of such changes and their effect, if any. If you have questions, please contact The Rhodes Human Resources Department at hr@rhodes.edu.

Anonymous (not verified) August 18, 2015

Medical Benefit Plan

Medical Benefit Plan

Plan Administrator. This Welfare Benefit Plan is administered by Rhodes College, 2000 North Parkway, Memphis, TN 38112 whose Internal Revenue Service Employer Identification Number is EIN620476301. The Plan Number is 501. The plan year is July through June. This is a contract administration plan and the third party administrator (TPA) is HealthSmart Benefits. Information regarding Plan eligibility, enrollment, cost, and the procedure for applying for benefits is contained in this section. The Plan Document which each covered employee receives without cost, includes a description of benefits under the Plan and the conditions under which these benefits are available to covered individuals. For a copy of the Plan Document please contact the Benefits Services Manager.

Employees Eligible for the Plan. All full-time faculty and staff and their dependents and qualified domestic partner are eligible to be enrolled in the Medical Benefit Plan, Part-time employees working an average of 30 hours per week are eligible to enroll in the Medical Benefit Plan. Employees working less than 30 hours per week are not eligible for medical coverage.

Date Eligible for Coverage. Each employee becomes eligible for medical coverage under the Plan the first day of the month following the date of employment with Rhodes.

Date Eligible for Dependent Coverage. A dependent shall become eligible for coverage on either (a) the first day that the employee becomes eligible for coverage and satisfies the definition of eligible dependent coverage or (b) the day a covered employee first acquires an eligible dependent. New dependents must be added to your medical coverage within 30 days of the event (i.e., marriage, birth, adoption or placement for adoption). The definition of the dependents eligible for coverage under this Plan appears in the Medical Benefit Plan Document, which each covered employee receives.

Enrolling in the Plan. An employee and his or her dependents may become enrolled on the date of first eligibility. Enrollment forms, which should be completed promptly, may be obtained from the Human Resources Office. Additional information about enrollment procedures, including special enrollment periods, may also be obtained from the Benefits Services Manager.

Plan A — PPO Benefits

  • 100% coverage after $30 office co-payment on physician’s charges if you see a physician participating in the Partner Solutions PPO network.
  • X-ray and lab charges are paid at 80% of PPO rate and the deductible waived for PPO Select providers.
  • $500 calendar year deductible per person (family maximum of 3). All eligible expenses apply toward the deductible except the $30 office co-payment, the 20% coinsurance for in-network X-ray and lab charges and prescription drug co-payments if purchased from a network pharmacy.
  • 80% coverage for eligible expenses after the deductible has been met.
  • 100% coverage on all eligible expenses after $2,500 per covered individual (plus deductible and co-payments) per calendar year has been paid out-of-pocket by the covered person.
  • Well baby care and routine exams.
  • Pre-admission certification is required for hospital admissions, observation stays, skilled nursing, MRI, CT and chemo/radiation therapy.

Plan A — Non-PPO Benefits

  • $600 calendar year deductible per person (family maximum of 3). All eligible expenses apply toward the deductible except prescription drug co-payments if purchased from a network pharmacy.
  • 50% coverage on eligible expenses after the deductible has been met.
  • Pre-admission certification is required for hospital admissions, observation stays, skilled nursing, MRI, CT and chemo/radiation therapy.

Plan B — PPO Benefits

  • $900 calendar year deductible per person (family maximum of 3). All eligible expenses apply toward the deductible except prescription drug co-payments if purchased from a network pharmacy.
  • 80% coverage on eligible expenses after deductible has been met.
  • 100% coverage on all eligible expenses after $3,500 per covered individual (plus deductible and co-payments) per calendar year has been paid out-of-pocket by the covered person.
  • Pre-admission certification is required for hospital admissions, observation stays, skilled nursing, MRI, CT and chemo/radiation therapy.

Plan B — Non-PPO Benefits

  • $1,200 calendar year deductible per person (family maximum of 3). All eligible expenses apply toward the deductible except prescription drug co-payments if purchased from a network pharmacy.
  • 50% coverage on eligible expenses after deductible has been met.
  • Pre-admission certification is required for hospital admissions, observation stays, skilled nursing, MRI, CT and chemo/radiation therapy.

Applications, Requests, and Questions Directed to the Plan Administrator. Applications, requests, and questions regarding enrollment, participation, or other administrative matters and service of legal process on issues arising from such questions, should be directed to the Plan Administrator, Chief Human Resources Officer, Rhodes College, 2000 North Parkway, Memphis, TN 38112, 901-843-3750.

The Cost of the Plan. Effective July 1, 1989, employees will be responsible for sharing in the cost of the Medical Benefit Plan through a medical benefit premium payment. At the employee’s option, medical benefit premium payments can be deducted through a flexible benefits program (pre-tax option).

Amendment to the Medical Benefit Plan. Rhodes shall be the Administrator for this Plan, and as such, shall have the authority to control and manage the operation and administration of the Plan. The Administrator has designated in writing the Chief Human Resources Officer to carry out duties under the Plan.

The Board of Trustees reserves the right to modify or discontinue the Plan at any time.

Anonymous (not verified) August 18, 2015

Prescription Drug Plan

Prescription Drug Plan

The Rhodes Prescription Drug Plan is part of the Medical Benefit Plan. Therefore, all full-time faculty and staff who participate in the College’s Medical Benefit Plan are eligible to participate in the Prescription Drug Plan. Effective July 1, 1996, all eligible employees and retirees may obtain prescription drugs at a negotiated price for themselves and their eligible dependents from any participating pharmacy.

Express Scripts, Inc. has a network of pharmacies that participate in our plan. The preferred pharmacies can identify covered persons and the Plan’s coverage provisions. To find out which pharmacies participate, contact Express Scripts, Inc at 1-800-451-6245.

The covered person must purchase the prescription drugs through a participating pharmacy or the mail order option.

Prescription Drugs – Express Scripts Participating Pharmacy

Retail Store

 Generic

$10

 Name brand formulary

 $30

 Name brand non-formulary

 $50 or 50% (whichever is greater)

Mail Order Program (90 day supply per prescription)

 Generic

$20 Generic

 Name brand formulary

 $60

 Name brand non-formulary

 $90

Note: The Rhodes College Handbook is not a contract of employment, nor should it be construed to create a contract with the College. Rhodes reserves the right to make future changes to its policies, practices, and fringe benefits. If such changes occur, the College will inform employees of such changes and their effect, if any. If you have questions, please contact The Rhodes Human Resources Department at hr@rhodes.edu.

Anonymous (not verified) August 18, 2015

Retiree Medical Benefit Plan

Retiree Medical Benefit Plan

Retiring employees and their eligible dependents that are currently on the active plan, may enroll in the Retiree Medical Benefit Plan upon completion of ten consecutive years of full-time employment after age 50. Employees hired after January 1, 1995 will not be eligible for medical benefits upon retirement.

To participate in the Retiree Medical Benefit Plan, a new enrollment form needs to be completed and returned to the Benefits Services Manager by the first day of the month after the employee’s retirement date. If the retired employee chooses not to enroll or cancels his or her participation after enrolling in the plan, reenrollment is not allowed. In case of death of the retiree, dependent coverage will continue until the spouse dies, remarries, or has other group medical benefits available to them (excluding Medicare). Employees retiring after June 30, 1989 will be responsible for sharing in the cost of medical coverage through medical benefit premium payments. Employees hired after January 1, 1995 will not be eligible for medical benefits upon retirement.

COBRA medical benefit continuation is also offered to retirees. A retiree may elect either the COBRA coverage or the Retiree Medical Benefit Plan (refer to the “COBRA” policy).

Note: The Rhodes College Handbook is not a contract of employment, nor should it be construed to create a contract with the College. Rhodes reserves the right to make future changes to its policies, practices, and fringe benefits. If such changes occur, the College will inform employees of such changes and their effect, if any. If you have questions, please contact The Rhodes Human Resources Department at hr@rhodes.edu.

Anonymous (not verified) August 18, 2015

Vision Insurance

Vision Insurance

Voluntary Vision Insurance

Plan Sponsor. This Plan is sponsored by Rhodes College, 2000 North Parkway, Memphis, TN 38112.

Eligible Participants. All full-time faculty and staff have the option to purchase vision insurance coverage for themselves, their domestic partner and their dependents.

Date Eligible for Coverage. Each employee becomes eligible for vision coverage under the Plan the first day of the month following the date of employment with Rhodes.

Date Eligible for Dependent Coverage. A dependent shall become eligible for coverage on either (a) the first day that the employee becomes eligible for coverage and satisfies the definition of eligible dependent coverage or (b) the day a covered employee first acquires an eligible dependent.

Benefits Provided. All services must be rendered by a provider in the VSP Signature Network

  • $10 annual exam
  • $25 materials copay for glasses and lenses every 2 years
    • Single vision lenses, line bifocals or trifocals
    • Frames up to $120
    • Elective contact lenses up to $120
  • Average 30% discount for all other materials

There is a charge for vision insurance coverage that is paid through payroll deduction. At the employee’s option, vision insurance premium payments may be deducted through the flexible benefits program (pre-tax option).

Currently the insurance company is Guardian Life Insurance Company. Request for information concerning Guardian Life Insurance Company contract terms, condition and interpretation thereof, claims thereunder, any requests for review of such claims and service of legal process may be directed in writing to: Guardian Life, 7 Hanover Square, H-26-E, New York, NY  10004.

The requirements for being covered under this Plan, the provision concerning termination of coverage, a description of Plan benefits (including any limitations and exclusions which may result in reduction or loss of benefits) are explained in the Certificate of Coverage.

Guardian Life offers a Vision discount plan to participants covered under the dental plan and their dependents who do not enroll in the Vision insurance. For additional information, please contact the Benefits Services Manager.

The plan year is July through June.
For a statement of ERISA rights see ERISA.

Note: The Rhodes College Handbook is not a contract of employment, nor should it be construed to create a contract with the College. Rhodes reserves the right to make future changes to its policies, practices, and fringe benefits. If such changes occur, the College will inform employees of such changes and their effect, if any. If you have questions, please contact The Rhodes Human Resources Department at hr@rhodes.edu.

Anonymous (not verified) August 18, 2015