Participants

Frequently Asked Questions

2017 PLAN CHANGES

Will we be able to select from two plans moving into 2018?

The Teachers Health Trust does not currently have a plan established to introduce new plans or tiers at this time. Nonetheless, the Trust will be continue to research and review options and innovations to include options, access and benefits for our participants. These efforts will include, but are not limited to, multiple plan options and/or additional tiered benefits.

Where can I locate the complete Plan Document?

The complete Plan Document can be found online here.

What is different about this year’s prescription benefits compared to 2016?

Throughout 2016, the Trust often received feedback from our participants in respect to the out-of-pocket costs for prescription drugs. The Trust heard your concerns and spent the better portion of the year determining how the costs could be brought down. The Trust is happy to announce that we will be able to reduce the maximum out-of-pocket costs by 50% for four tiers of prescription drugs:

Retail 30-Day Prescriptions

  • Generic Medications over $25 dollars out-of-pocket maximums will be reduced from $100 to $50.
  • Preferred Formulary out-of-pocket maximums will be reduced from $200 to $100.

Mail Order 90-Day Prescriptions

  • Generic Medications over $25 dollars out-of-pocket maximums will be reduced from $300 to $150.
  • Preferred Formulary out-of-pocket maximums will be reduced from $600 to $300.

Emergency Drug List

2016 saw astronomical increases to many emergency drugs. While these increases were out of the control of the Trust, we have added them into a separate formulary tier in order to reduce your out-of-pocket costs. This Emergency Drug List tier will be added to the formulary at with a coinsurance of 25% of the cost of the prescription with a copayment maximum of $100 per prescription per 30-day supply and shall include the following drugs:

  • Epi-Pen
  • Epi-Pen Jr.
  • Glucagon Emergency Kit
  • Narcan Nasal Spray

OPERATIONS / FINANCIALS

Is it possible to have a meeting with the appeals committee if there is a pending appeal?

The appeal process that the Trust has implemented follows the guidelines of the Affordable Care Act (ACA). The Trust’s appeal process includes a three-tier policy, which provides participants the opportunity to attend and take an active role at the 2nd tier (Appeals Committee). The participant must simply provide formal notification of their intent to attend when completing the appeals packet.

Will our plan have significant changes in 2017?

The short answer to this question is yes. That being said, though, it is important to make clear that all changes made to the plan for 2017 have been incorporated in order to decrease out-of-pocket costs to you. The Trust is implementing a series of enhancements to the plan, such as reduced prescription cost maximums, that are all primarily focused on increasing access and reducing costs for our participants.

Referrals/Prior Authorization

What is a referral?

A referral is issued by (in most cases) your Primary Care Provider in order facilitate ease of access to medical care from a specialist. It is a recommendation to seek further care from a provider more tailored to the care you need.

Do I have to have a referral?

No. You may forgo obtaining a referral to see a specialist as outlined within the Plan Document. However, please note that you will incur greater out-of-pocket costs when doing so without a referral in place.

What is the value of a referral?
  • One doctor (your Primary Care Doctor) oversees your care and collaborates with you and a team of quality specialists to help you obtain the care you need.
  • Your doctor will know your medical history and will be involved in coordinating all aspects of your care. This will allow you and your doctor to keep your health information up to date in order to ensure an easily treatable condition does not turn into a long-term concern.
  • Your doctor will be able to refer you to an in-network specialist that will best meet your needs, and who may be available to see you quicker than with most traditional cold-call scheduling.
  • Your doctor communicates with your specialist to ensure that you receive the right care for you and that your health information stays up to date.
If my provider puts a referral in for me, does that mean I have an appointment already?

No. Placing a referral into the system does not mean that you have an appointment. You still need to contact the provider’s office that you intend to visit in order to schedule an appointment.

Do I need a referral to see behavioral health specialist?

No. You can contact the therapist of your choice to schedule directly. Be sure to call Human Behavior Institute Network to ensure that the provider you wish to see is an in-network therapist. You can also visit www.hbinetwork.com to search the provider network directory to verify. If you need to seek care beyond traditional therapy, your therapist will issue a referral.

If someone in my family has a true emergency and cannot obtain a referral prior to getting care, will we be penalized?

No. In the event of a true emergency, no referrals are required for medical care. For the purpose of coverage, a true emergency is defined as seeing a provider in connection with an unforeseen injury or illness requiring surgical or medical attention within 24 hours after the onset, and from which, in the absence of such care, the participant could reasonably be expected to suffer serious physical impairment or death.

BENEFITS AND ELIGIBILITY

What is the limit for Physical Therapy in 2017?

The first 20 physical therapy visits in a calendar year may be obtained without authorization. If you require additional visits beyond 20, your provider will need to obtain authorization for long-term therapy. Once authorized for long-term therapy, authorization only needs to be renewed after 60 visits or 6 months, whichever occurs first.

What is the limit for Speech Therapy in 2017?

The first 20 speech therapy visits in a calendar year may be obtained without authorization. If you require additional visits beyond 20, your provider will need to obtain authorization for long-term therapy. Once authorized for long-term therapy, authorization only needs to be renewed after 60 visits or 6 months, whichever occurs first.

If the doctor I need to see is not in Clark County, will I be covered going outside of the county or state?

Yes, you may visit a doctor outside of the county or state, but your out-of-pocket costs will be calculated under the out-of-network benefits (See Page 89 of the Performance Plus Plan Document). If your physician believes that a service you need requires you to go out of state because it is unavailable in-network, authorization for the Extended Network Benefit may lower your out-of-pocket costs when authorized.

What are my coverage options if I am traveling out of town during the summer?

Your coverage options include using WellHealth Online (Telemedicine), Urgent Care, CVS Minute Clinics or, in the event of a true emergency, the Emergency Room. For detailed information, please refer to pages 62-63 of the Performance Plus Plan Document.

What is included in the maximum out-of-pocket cost?

Any In-Network eligible expenses for Medical and Prescriptions benefits (only formulary drugs on the list).

Can you offer discounts for a gym membership?

The Plan will pay up to $50 per Calendar Year for the following health improvement programs and activities:

  • Health Club Memberships
  • Personal Training (The Trust may audit personal trainers to ensure appropriate and up-to-date licensing and certifications are in order for their field of expertise.)
  • Tobacco Prevention Counseling and Education
  • Weight Management Support Groups (for example, TOPS, Inc., Jenny Craig, Weight Watchers, etc.)

This benefit is available to the primary subscriber only. For additional information, please see the Health Improvement Benefit in the Performance Plus Plan Document.

I need to have a minor outpatient surgery. What are some of the costs that will be associated with this, and who should I reach out to in order to determine exact costs?

Outpatient Surgery in the physician’s office, with a referral, has a coinsurance of 20% (deductible does not apply). Outpatient surgery in a facility has a copayment of $400 (deductible does not apply). The Surgeon and the Anesthesiologist each have a 20% coinsurance after the deductible is met. The calendar year out-of-pocket maximum for an individual participant is $6,850.

While the above provides the portion of the cost you are responsible for an outpatient surgery, the Trust cannot predict your total costs. The final cost will depend upon what services, procedures, etc. are billed in respect to your surgery. The Trust highly encourages you to speak to your provider prior to surgery to assist in determining what services and procedures will be included in your case.

What will my copayments be for the 2017 Performance Plus Plan?
  • Preventive care from your PCMH provider will have a $0 copayment;
  • Office visits to your PCMH provider will have a $10.00 copayment, plus 20% coinsurance for all other services (deductible does not apply);
  • Office visits to a specialist, with referral, will have a $20.00 copayment, plus 20% coinsurance for all other services (deductible does not apply).

For detailed copayment and coinsurance information on other services, please click here.

Where can I find the Plan Document?

The complete Plan Document can be found online here

How much will my premiums be in 2017?

There will be no increases to the current premium structure and/or amounts applied for 2017.

Why is there no premium for 2 CCSD Employees and their Family? Am I paying for them with my premiums?

No. You are not paying for other participants on the plan. The Teachers Health Trust receives a contribution for each CCSD employee. For the majority of participants, this results in the Teachers Health Trust receiving a single contribution for a household (family). However a household with two CCSD employees results in the Trust receiving two contributions for a single household. This additional contribution offsets that household's premium payment, resulting in no per paycheck deduction for the household.

Can I change my Patient-Centered Medical Home Provider?

Yes, all participants will be able to change their PCMH providers once per quarter. You may do so by using the Provider Change Request Form and submitting it through the WellHealth Healthcare Advocates at advocates@wellhealthqc.com. Once you change your Primary Care Physician (PCP), you will be able to see that provider on the first day of the following quarter.

How often can I change my PCMH Providers?

All participants will be able to change their PCMH once per quarter. Once you change your PCMH, you will be able to see that provider on the first day of the following quarter.

Do I need a referral for a psychiatrist or other mental health specialist?

Referrals are not required for behavioral health. However, prior authorization may be required. All behavioral health care is available to Teachers Health Trust participants through the Human Behavior Institute (HBI). They will assess and find a provider that best suits your needs.

TELEMEDICINE

What is Telemedicine?

Telemedicine is an online virtual visit with a provider that acts as "bridge care" - that is, care meant to hold you over until you can visit your chosen PCMH provider. Telemedicine is meant to be utilized in place of the quick care or emergency rooms for non-emergent or nonlife-threatening symptoms. This service is provided 24 hours a day, 7 days a week.

You can access Telemedicine through the WellHealth Quality Care App for your smart phone, or online at wellhealthonline.com. This service is provided for Teachers Health Trust participants at no out-of-pocket cost

What is Teletherapy?

The Teletherapy benefit is available to participants at a no cost to you. This benefit provides you with the opportunity to speak with a licensed therapist via video chat in the comfort and privacy of your own home.

Who can access Telemedicine?

Telemedicine is available for all Teachers Health Trust participants and enrollees 24 hours a day, 7 days a week, nationwide, and anywhere you have access to the internet. It is incredibly convenient and easy to use. You can also use Telemedicine in Puerto Rico, Guam, and the US Virgin Islands. Telemedicine is not available in Arkansas.

You can access Telemedicine through the WellHealth Quality Care App for your smart phone, or online at wellhealthonline.com. This service is provided for Teachers Health Trust participants at no out-of-pocket cost.

How do I register for Telemedicine?

Visit WellHealthOnline.com and follow the directions to register. You will need to add two additional zeroes (00) to the end of your Member ID Number. Further instructions can be found here: wellhealthonline.com.

OTHER COMMONLY ASKED QUESTIONS

My child is away to College and has Teachers Health Trust insurance. What doctor can he/she see?

If your child happens to get sick while they are away at school, they can always access a provider through telemedicine at no out-of-pocket cost to them or your family. Telemedicine is available for all Teachers Health Trust participants and enrollees 24 hours a day, 7 days a week, nationwide, which means it is great for students away at school.

Telemedicine is an online virtual visit with a provider that acts as "bridge care" - that is, care that is meant to hold your child over until they can go see their chosen PCMH provider back home. Telemedicine is meant to be utilized in place of the quick care or emergency rooms for non-emergent or nonlife-threatening symptoms.

You can access Telemedicine through your smart phone (a download option will be available soon), or online at wellhealthonline.com.

There are also a few providers available in Northern Nevada . Please check the complete Network Provider List for a full listing of in-network providers that are located outside the Las Vegas Valley and surrounding areas.

Your child can also see any provider that is not in-network, but at a higher out-of-pocket cost. In addition, all true emergencies are covered nationwide, so if your child has to visit an emergency room, you can be rest-assured that any true emergencies will be covered.

I have a physician that I would like to have added back to the Network. What can I do?

All providers are welcome to apply to join the WellHealth Network. Your provider is welcome to visit our website at https://www.wellhealthqc.com/doctors to find everything that they need to apply. You are also welcome to submit a letter of appeal to our Provider Relations Team at networkrelations@wellhealthcq.com.

Please be aware that there are no guarantees that your provider will be accepted to join the network; however, we do review every request. Additionally, the standard time it takes to have a provider added is 2-3 months, so it will be some time before you will be able to see them.

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