Plan Administrator. This Medical 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 may receive 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.
Rhodes College 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, subject to the provisions of the Group Insurance Policy. The Administrator has designated the Chief Human Resources Officer to carry out duties under the Plan.
Applications, requests, and questions regarding enrollment, participation, or other administrative matters, as well as service of legal process should be directed to the Chief Human Resources Officer, Rhodes College, 2000 North Parkway, Memphis, TN 38112, 901-843-3750.
Employees Eligible for the Plan. All full-time employees and their dependents 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 an employee’s 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.
Enrolling in the Plan. An employee and their dependents may become enrolled on the date of first eligibility. Enrollment forms, which should be completed promptly, will be processed in Workday. Additional information about enrollment procedures, including special enrollment periods, may also be obtained from the Benefits Services Manager.
Available Plans. Employees may select from the following plans, each of which has a different cost and provides different levels of benefits.
Plan A — PPO Benefits
- 100% coverage after $30 office co-payment on physician’s charges if the employee sees 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.
Plan Premiums. Employees are 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). For the premium costs for each plan option, contact the Benefits Services Manager.
Plan Amendments. 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.
How to Submit a Claim. When a Covered Person has a claim to submit for payment, that person must:
- Obtain a claim form from the Human Resources Office or the Plan Administrator.
- Complete the Employee portion of the form. All questions must be answered.
- Have the Physician complete the provider’s portion of the form.
- 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
- Send the above to the Claims Administrator at this address:
Benefit Solutions, Inc.
P.O. Box 16207
Lubbock, TX 79490
(844) 792-4159
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:
- Request from the Plan Administrator a review of any claim for benefits. Such request must include: the name of the Employee, their Social Security number, the name of the patient and the Group Identification Number, if any.
- 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 lawsuit for benefits.