A. No. Since your child was not continuously covered as a dependent under your Trust health plan, you cannot add her to your coverage after she becomes disabled.

A. That depends. If your disabled dependent child is age 19 or older, you may not enroll him or her under your Trust plan because you did not maintain continuous health coverage on the child. However, you may enroll the child if he or she is under age 19.

A. Yes. You must provide proof of your child’s full–time student status even if your child is age 19 or older and still in high school.

A. You must pay the $100 administrative fee and all applicable premiums to reinstate dependent coverage. In no event will a request for late enrollment be granted if the documentation is received by the Trust office more than 30 days from the deadline date.

A. No. In order to add your child to your coverage, you will need to complete a change form and submit it to the Trust along with a copy of the certified birth certificate within 31 days of the baby’s date of birth. All documents must be received within 31 days in order to avoid a $100 administrative fee.

Regardless of whether you are waiting to receive your newborn’s birth certificate, please submit the change form as soon as possible, as you may request an extension (within the first 31 days) for submitting the birth certificate and can thereby avoid the administrative fee.

Under no circumstances will eligibility be granted if the required documents are submitted more than 60 days after the birth of the baby.

A. Yes. You will need to complete a change form and a domestic partnership enrollment form and submit them to the Trust along with copies of the certified birth certificates for all dependents to be covered.

A. No. You have 31 days from the date the divorce is final to submit a copy of your divorce decree (which has been signed by a judge and filed with the court) and the change form that will remove your ex–spouse. The Trust requires a copy of the front page of the divorce decree showing the filing stamp, the page with the judge’s signature, and any page that pertains to custody and insurance coverage for children (if applicable). If the required documents are not received within 31 days from the date of the divorce, you will forfeit any premiums paid for the ineligible dependent. In addition, if any claims are paid for that dependent while that dependent was not eligible for coverage, you will be responsible for reimbursing the Trust any moneys paid on their behalf. If you and your ex–spouse are both CCSD employees and you have been paying a reduced premium or have had no premium, you will be responsible for paying any applicable premiums due starting from the date you no longer qualified for the two CCSD employee credit.

A. Yes. You have 31 days from the date his coverage terminates to add him to your coverage. You will need to submit a change form along with a copy of the HIPAA certificate (also known as a certificate of creditable coverage). His coverage would become effective the day after his other coverage terminated. If the required documents are not received within 31 days from the date your spouse’s coverage terminates, you can still add him to your plan; however, you must pay a $100 administrative fee. Under no circumstances will eligibility be granted if the required documents are submitted more than 60 days from the date the other coverage ended.

A. You must file a report of injuries and/or illness incurred at work within seven (7) days of the incident.

A. Yes. If you are participating in any school activities (such as field trips or other events) during or after school and you incur an injury or illness during that time, you must file a workers’ compensation claim within seven (7) days of the incident.

A. Yes. Depending upon the circumstances, workers’ compensation may cover you should an injury occur while you travel from your vehicle to the building and from the building to your vehicle.

A. Report your injury or illness to your administrator immediately and then contact the Clark County School District’s Risk Management Office at 702–799–2967.

A. The Trust will not consider claims if workers’ compensation is denied because you failed to file the claim within a timely manner. Remember, you must report your injury or illness immediately.

A. You will have to complete a Form C–1 at your place of employment, a Form C–4 at your treating physician’s office, and a TPL or Third Party Liability Form from the Teachers Health Trust.

A. It is not up to you to make that determination. If the Trust deems the injury to be work–related, the Trust will not pay for services, and you will be responsible for any and all charges related to the incident.

A. The DIAMOND and PLATINUM Plans provide benefits for inpatient and outpatient medical care, including (but not limited to) hospitalizations and surgery, medical office visits, preventive/routine care, physical therapy, durable medical equipment (DME), and prescription drugs. Certain benefits, such as hearing aid services, are only covered under the DIAMOND Plan.

A. Yes, the plan will allow benefits for covered medical services regardless of when your medical condition began. Neither the DIAMOND Plan nor the PLATINUM Plan restrict coverage for pre–existing conditions.

A. Both plans do have in–network providers who have agreed to provide their services at a negotiated fee. Using these providers will save you money. You may also use the services of a provider who is not in the Trust’s network of contracted providers, but you will pay more out of your own pocket for those services. For more information, please refer to Out–of–Network Services in the Medical section of the Summary Plan Document (SPD).

A. No. Neither the DIAMOND Plan nor the PLATINUM Plan will cover expenses incurred for complications that result from non–covered treatment or procedures.

A. Most of your questions will be answered in the SPD. (You may wish to search the Index at the back of the SPD for the topic of your question.) However, you are always welcome to contact the Trust’s service staff. The Service Team is available by telephone at 702–794–0272 or 800–432–5859 or via e–mail by clicking here.

A. No. Regardless of whether a typically covered service is provided as part of your concierge care, any fee for services that are included in the concierge care fee will not be considered a covered expense and will not be reimbursed.

A. The DME will be paid at the out–of–network level of benefits. You will be responsible for any portion of the out–of–network calendar year deductible that you have not yet met as well as 30 percent of the Trust’s allowable amount. You will also be required to pay any amount that the provider charges over the Trust’s allowable amount.

A. While there may be times when you will be unable to find an in–network provider who can provide you with the prescribed DME, using these three simple steps may help reduce your personal expense:

• First, ask your doctor in advance what providers he or she recommends for the DME.
• Then, go to providerdirectory.teachershealthtrust.org and search the Provider Directory to see if the DME provider is in the Trust’s network
• Finally, if the provider is not in the network, print the names of the in–network providers and ask your doctor to refer you to one of them.

A. Get your doctor involved!

Of course, whenever possible, you should try to use in–network providers for your DME. If he or she has prescribed DME that only an out–of–network provider can supply, ask if there is an alternative piece of equipment that may be appropriate for your condition that can be provided by an in–network provider.

Finally, DME has many options with varying prices. You pay a percentage of the allowable amount, so you should ask your physician to prescribe a brand that is appropriate for your needs as well as your personal budget.

A. Prior authorization is always required for certain services. In an emergency, authorization should be obtained within 24 hours of the service to be rendered. To view a list of services that require prior authorization, please refer to the Prior Authorizations section of the Medical chapter in the SPD.

A. The Trust will waive the out–of–network deductible and apply the in–network copayments and coinsurance listed in the Emergency Services section of the SPD. You will also be responsible for all charges above the in–network allowable amounts.

A. If you normally reside within the service area* and had emergency services outside the service area, you will be responsible for the in–network copayments and coinsurance listed in the Emergency Services section of the SPD.

A. If you normally reside within the service area* and received urgent care services from an out–of–network provider, you will be responsible for 30 percent of the allowable amount. You will also be responsible to pay any amount the provider charges over the Trust’s allowable amount. (Please refer to the Out–of–Network Services section of the Medical chapter in the SPD for additional information.)

A. If you normally reside outside of the service area and you receive emergency services from an out–of–network provider, you will be responsible for the deductible, coinsurance, and any amount the provider bills in excess of the allowable amounts as described in the Out–of–Network Services section of the Medical chapter in the SPD.

* To reside within the service area means you and your dependents live or work in the service area at least nine months of each calendar year and you and your dependents have not moved out of the service area prior to receiving services.

A. Since he normally resides outside of the service area, covered emergency services from an out–of–network provider will be processed according to the Out–of–Network Services section of the Medical chapter in the SPD, and you will be responsible for the deductible, coinsurance, and any amount the provider bills in excess of the allowable amounts.

A. Covered emergency services will be processed according to the in–network benefits listed in the Emergency Services section of the SPD.

A. If it is safe to do so, he must return to the service area. If he chooses to receive physical therapy in Nebraska, claims will be processed according to the Out–of–Network Services section of the Medical chapter in the SPD, and you will be responsible for the deductible, coinsurance, and any amount the provider bills in excess of the allowable amounts.

A. Based on the diagnosis, out–of–network benefits will apply. This means that you will be responsible for paying 30 percent of the allowable amount PLUS any amount the provider charges in excess of the allowable amount. Keep in mind that charges from a hospital emergency room will be much higher than charges from an urgent care clinic or physician’s office.

A. This would be considered an urgent service. (See Urgent Care Services in the Medical chapter of the SPD.)

A. No. You are only responsible for the inpatient copayments listed in the Medical chapter of the SPD.

A. If you normally reside within the service area and have an emergency hospitalization, you will be responsible for the in–network copayments listed in the Hospital Services section of the SPD. You will also be responsible for paying any amount the provider charges over the Trust’s allowable amount. (See Allowable Amounts at the beginning of the Medical chapter in the SPD.)

If your hospitalization was pre–planned, or if you normally reside outside the service area, you will be responsible to pay the deductible and coinsurance listed in the Out–of–Network Services section of the Medical chapter in the SPD PLUS any amount the provider charges above the Trust’s allowable amount.

A. Using these three simple steps may reduce your personal expense for your hospitalization:

• First, ask your doctor in advance what other providers he will be using during the hospitalization (such as hospital, hospitalist, anesthesiologist, and assistant surgeon).
• Then, go to providerdirectory.teachershealthtrust.org and search the Provider Directory to see if the provider is in the Trust’s network.
• Finally, if one or more of the providers is not in the network, print the names of the in–network providers and ask your doctor to refer you to one of them.

A. If the hospitalist is an in–network provider, you will be responsible for paying in–network copayments.

However, if the hospitalist is an out–of–network provider, you will be responsible for the out–of–network deductible, coinsurance, and any amounts the physician charges above the Trust’s allowable amount.

A. That depends. You will, of course, receive a bill for your portion of the hospital charges and physician charges (if any). You may also get bills from a radiologist or pathologist. If you had surgery while you were in the hospital, you may get additional bills. Surgeon, assistant surgeon, and anesthesiology billings are the most common, but it is possible you may receive bills from other providers, too.

When you receive a bill at home, it is very important that you check online with the Trust to make sure the bill has been processed as a claim under your benefit plan.

A. That depends on your obstetrician. Generally, he or she will charge you one flat fee for your prenatal care, delivery, and postnatal care. The Trust will pay the benefit to your obstetrician after your delivery. Your obstetrician may bill you for your balance after the Trust pays, or he or she may work out a schedule with you for payments to be made throughout your pregnancy. You should discuss this with your physician’s billing department.

A. If you change obstetricians during your pregnancy, you will be responsible for paying your original obstetrician the office visit copayments for each visit you incurred. You will also be responsible for paying your new physician the copayment (or coinsurance in the event he or she is not an in–network provider) listed under Total OB Care and Delivery in the Maternity/Pregnancy Services section of the SPD.

A. Yes, all inpatient hospitalizations require prior authorization. To obtain authorization, your obstetrician should contact Encompass at 800–779–4158 prior to your hospitalization.

A. Yes, if your daughter is an eligible dependent under your coverage, your daughter’s maternity/pregnancy care will be covered through her delivery and routine postnatal care. The plans do not cover any expenses related to the newborn.

A. Yes, the DIAMOND Plan and the PLATINUM Plan cover the services of a properly licensed nursemidwife in the same manner that obstetricians are covered. For coverage information, refer to Obstetricians in the Maternity/Pregnancy Services section of the SPD.

A. No. Expenses for surrogate mother services are not payable under either the DIAMOND Plan or the PLATINUM Plan.

A. No. Breast pumps are not covered under either the DIAMOND Plan or the PLATINUM Plan.

A. High–risk pregnancies, as defined by the Trust, are covered under both the DIAMOND Plan and the PLATINUM Plan. Because you will likely require specialty services, you will be required to pay separate copayments (or deductibles and coinsurance, if out–of–network) for those services. For example, if you require the services of a perinatologist in addition to your regular obstetrician, you will pay separate office visit copayments (or coinsurance) to that specialist.

High–risk pregnancies include:

• Twins, triplets, or other multiple gestations
• Pregnancies that require the services of a perinatologist
• Pregnancies determined by the obstetrician to be “high–risk”
• Any pregnancy involving a hospital admission during the pregnancy that is not connected with the routine delivery of the child
• Any pregnancy determined to include a fetal abnormality
• Any pregnancy involving excessive nausea and vomiting that results in weight loss
• Any pregnancy involving threatened or preterm labor
• Any pregnancy that involves additional medical diagnoses, such as diabetes, blood disorders, or hypertension
• Pregnancies that result in unusual physical or mental stress
• Any pregnancy where the patient has a history of miscarriage
• Any pregnancy where the patient has a history of preterm labor with or without preterm deliveries.

Contact the Trust’s RN Case Manager at 866–585–CARE (2273) to coordinate services during your high–risk pregnancy.

A. Both the DIAMOND Plan and the PLATINUM Plan provide coverage for pregnancy terminations, also known as “therapeutic abortions” or “abortions.” For coverage information, please refer to Surgical Services in the Medical section of the SPD.

A. Prenatal vitamins are covered under the Trust’s Prescription Drug Plan. Please refer to that section of the SPD for additional information.

A. No. The DIAMOND and PLATINUM Plans will not cover expenses related to egg or sperm donors or storage or related to determining gender.

A. That depends. Prior authorization is generally NOT required for covered prescription drugs. However, certain classes of drugs (for example, growth hormones) require prior authorization before you can fill the prescription. To determine if your particular medication requires prior authorization, or to obtain the prior authorization, you must contact Medco at 800–818–2364.

A. You may obtain your prescription in one of two ways:

1. Pay the full amount due for your prescription at the time of purchase, then send the prescription receipt to the Trust for reimbursement; or
2. Contact the Trust Service Department at 702–794–0272 or 800–432–5859 to guide you through obtaining your prescription at copayment levels.

A. You can request a new prescription card by calling Medco at 800–818–2364 or by logging on to Medco’s website at www.medcohealth.com.

A. If you are an established customer at a particular pharmacy, you should not have to present your card to them because they usually have all the required information stored in their computer system. If you are using a new pharmacy, you or your pharmacist can call Medco at 800–818–2364. Medco will instruct the pharmacist on how to process your prescription claim online so that you are only charged the appropriate copayment.

A. Although not every brand–name drug has a generic equivalent, you can save a significant amount of money by choosing generic drugs whenever available without compromising quality. Generic drugs typically cost 30 to 60 percent less than their brand–name counterparts because manufacturers don’t have to pay for expensive research and development or sales and advertising. Plus, your copayment for generic drugs is much lower than your copayment for brand–name drugs.

A. The U. S. Food and Drug Administration tests new generic drugs to ensure their safety and effectiveness. They make sure that generic drugs contain the same amounts of active ingredients, that they are manufactured according to federal standards, and that they are released into the body at the same rate and in the same way as the brand–name equivalents.

A. You may not obtain an early refill of your prescription unless 75 percent or more of your existing supply has been used as directed by the prescribing provider. If the existing supply on hand is less than 75 percent used, you must pay the full cost of the refill.

A. Absolutely, but you will be required to use the primary plan’s prescription drug benefits first. If the other coverage is primary, you will have to pay your portion of the cost of the drug and submit a claim to the Trust for reimbursement. Prescription drug claims must include the following information for you to receive reimbursement:

• National Drug Code (NDC) number
• Your name and identification number (Since prescription receipts do not include identification numbers, be sure to write your number on the receipt.)
• Patient’s full name
• Name and quantity of drug
• Prescription number
• Name of prescribing doctor
• Amount charged for each drug
• Purchase date of prescription
• Pharmacist’s signature

Within twelve months, submit your original prescription receipt* with all the required information and a copy of the other insurance company’s explanation of benefits (if applicable) to:

Teachers Health Trust
P. O. Box 96238
Las Vegas, NV 89193–6238

The claim must be submitted no later than 12 months following the date your prescription was filled.

*In lieu of an original prescription receipt, the Trust will accept a printout of your prescription history with the pharmacist’s signature.

A. If you normally reside within the service area and had emergency surgery, you will be responsible for the in–network copayments listed in the Anesthesia Services or Surgical Services sections of the SPD. You will also be responsible for paying any amount the provider charges over the Trust’s allowable amount.

If your surgery was pre–planned, or if you normally reside outside the service area, you will be responsible for paying the deductible and coinsurance listed in the Out–of–Network Services section of the Medical chapter in the SPD PLUS any amount the provider charges above the Trust’s allowable amount.

A. Using these three simple steps may reduce your personal expense for your surgical procedure:

• First, ask your doctor in advance what other providers he will be using during the surgery (including hospital, hospitalist, anesthesiologist, and assistant surgeon).
• Then, go to www.teachershealthtrust.org and search the Provider Directory to see if the provider is in the Trust’s network.
• Finally, if one or more of the providers is not in the network, print the names of the in–network providers and ask your doctor to refer you to one of them.

A. Hospitalists are doctors whose primary focus is the general medical care of hospitalized patients. Hospitals often assign a hospitalist to a patient when the patient enters the hospital through the emergency room or other hospital admission. Some physicians hire hospitalists to visit their hospitalized patients, which gives the physician the opportunity to keep his or her regular office appointments.

Just as the Trust contracts with physicians and provides you with a list of in–network providers, the Trust also contracts with hospitalists. However, it is possible that during your stay in the hospital, you could unknowingly be seen by an out–of–network hospitalist, which would greatly increase your out–of–pocket expenses.

To ensure all your physicians are in–network, advise the admissions staff that you should be seen only by providers in the Trust Network. Question any unfamiliar doctor who enters your room, confirming that he or she is contracted with the Trust, and be sure any family member or friend speaking on your behalf knows to request in–network providers only.

A. If you normally reside within the service area and were assigned an out–of–network hospitalist during emergency circumstances, you will be responsible for the in–network copayments listed in the Surgical Services section of the SPD. You will also be responsible for paying any amount the provider charges over the Trust’s allowable amount.Please refer to the Out–of–Network Services section of the Medical chapter in the SPD for additional information.

A. If the hospitalist is an in–network physician, you will be responsible for paying in–network copayments.

However, if the hospitalist is an out–of–network provider, you will be responsible for payment of the out–of–network deductible, coinsurance, and any amounts the physician charges above the Trust’s allowable amount.