Health benefits
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Learn more about the AFTRA Health Plan with the following Frequently Asked Questions and answers.
 

Health benefits

What are my Network Major Medical benefits?

As an enrolled participant, once the Network deductible has been satisfied in each calendar year, the Individual and Family Health Plans will pay 90% of your the next $10,000 in covered expenses. The Plans also will pay 100% of your covered expenses over that amount. Your annual out-of-pocket coinsurance costs will be no more than $1,000 plus the deductible and any applicable copayments. See pages 38 and 39 the 2005 Health Plan Summary Plan Description and relevant Benefits Updates.

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What are my non-Network Major Medical benefits?

As an enrolled participant, once the non-Network deductible has been satisfied in each calendar year, the Individual and Family Health Plans will pay 60% of the next $8,000 in scheduled allowances for your covered expenses. The Plans also will pay 100% of the scheduled allowances for your covered expenses over that amount. It is important to note that the non-Network benefit calculates reimbursements based on Plan scheduled allowances and not the amounts billed by the providers. The scheduled allowance is based on the highest amount charged for the specific service by 70% of health care providers in the geographic area. Your annual coinsurance out-of-pocket costs will be no more than $3,200 plus the deductible and any applicable copayments. However, when you utilize non-Network providers your annual out-of-pocket costs may be higher than $3,200 because you also are responsible for that portion of any provider charges which exceed the Plan scheduled allowances. For a complete definition of “scheduled allowance” and additional information, see pages 38 and 39 the 2005 Health Plan Summary Plan Description and relevant Benefits Updates.

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What are my Network inpatient hospital benefits?

For all enrolled participants there is a $100 copayment for each inpatient hospital admission; no deductible is required. Then, the Individual and Family Health Plans will pay 90% of the first $10,000 in covered expenses in a calendar year. The Plans also will pay 100% of any additional covered expenses you incur during that same year. Your annual coinsurance out-of-pocket costs will be no more than $1,000 (excluding the $100 per admission copayments). All inpatient Network hospital admissions must be pre-certified by calling CareAllies at 1-800-768-4695. See pages 32 and 33 of the 2005 Health Plan Summary Plan Description and relevant Benefits Updates.

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What are my non-Network inpatient hospital benefits?

For all enrolled participants there is a $100 copayment for each inpatient hospital admission; no deductible is required. Then the Individual and Family Health Plans will pay 60% of the first $7,000 in covered expenses in a calendar year. The Plans also will pay 100% of any additional covered expenses you incur during that same year. Your annual out-of-pocket costs for the use of non-Network hospitals will be no more than $2,800 (plus any non-covered expenses). All inpatient non-Network hospital admissions must be pre-certified by calling CareAllies. See pages 32 and 33 of the 2005 Health Plan Summary Plan Description and relevant Benefits Updates.

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Are there any situations in which a higher level of non-Network inpatient hospital benefits are available?

Yes, in two specific situations (see below), the Individual and Family Health Plans will pay 80% of the covered expenses after the $100 per admission copayment, leaving the enrolled participant to pay 20%.

  • If the non-Network hospital is located in a part of the country where there are no Network hospitals; or
  • If the admission was the result of a medical emergency that precluded the use of a Network hospital.

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Do I have to pre-certify if I am admitted to a hospital?

Yes. You, your doctor or the hospital must call CareAllies at 1-800-768-4695 before you are admitted to any hospital. For any inpatient hospitalization due to a medical emergency, pre-certification must be obtained within 72 hours of admission. Otherwise benefits will be reduced.

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What is the Network annual deductible for Major Medical benefits?

$200 per individual with a maximum of $400 per family.

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What is the non-Network annual deductible for Major Medical benefits?

$400 per individual with a maximum of $800 per family.

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Are there lifetime benefit maximums?

Yes. The maximum is $1 million for Major Medical benefits. This includes charges for mental health and chemical dependency treatment. This maximum does not include benefits provided through the Hospital Program. A separate $1 million maximum applies for hospital and prescription drug benefits combined.

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How do I find out if my doctor or hospital is in the Network?

Search for Network health care providers online at our Web site. For all states except California, search the Cigna Medical Shared AdministrationSM PPO Network or call 1-800-768-4695. To find Network health care providers in California, search the Anthem Blue Cross’ Prudent Buyer PPO Network or call Participant Services at (800) 562-4690.

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If I am traveling outside of the US, does the AFTRA Health Plan pay for health care services that I receive?

Yes. The Individual and Family Health Plans will reimburse medically necessary health care treatment, services and supplies you receive in a foreign country based on the Major Medical and Hospital Program exception addressing situations where Network providers are not located in the geographic area. Foreign claims must be submitted to the AFTRA Health Fund at: 261 Madison Avenue, 7th Floor, New York, NY 10016, Attention: Claims Department.

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What happens if my spouse and I are covered under two different health plans?

The AFTRA Health Plan coordinates benefits with other health plans. If you are covered by two plans, one will pay benefits first (the primary plan), and the other (the secondary plan) will pay its share of the remaining charges (if any) up to 100% of allowable expenses minus any deductibles. For more information about allowable expenses or how coordination of benefits works, please see “Coordination of Benefits,” pages 66-70 of the 2005 Health Plan Summary Plan Description and relevant Benefits Updates.

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Does the AFTRA Health Plan cover physical and occupational therapy?

Yes, and no pre-authorization is required. Enrolled participants are limited to 12 visits in a calendar quarter. The Plan will reimburse covered expenses for visits in excess of 12 per calendar quarter up to the annual 48 visit maximum for all therapy, chiropractic and acupuncture treatment upon written request and if approved following medical review. Please see page 39 of the 2005 Health Plan Summary Plan Description and relevant Benefits Updates.

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Does the AFTRA Health Plan cover expenses for drug and alcohol rehabilitation?

Yes. The Chemical Dependency Program offers coverage for the treatment of chemical dependency, including alcohol and drugs. This program is administered by ValueOptions. Patients will be referred by ValueOptions to counselors and to other services as appropriate. In order to receive reimbursement, you must obtain a referral and pre-authorization for treatment from ValueOptions. You must also complete your treatment program to receive the full reimbursement. You can reach licensed clinicians at ValueOptions 24 hours-a-day, seven days a week by calling 1-800-704-1421. See pages 44-47 of the 2005 Health Plan Summary Plan Description and relevant Benefits Updates.

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