- Issue Date: July 1, 1997
- Primary Contact: Director of Human Resources
- Responsible Member of Directorate: President and Director
- Responsible Office: Human Resources
The Institution provides group medical and dental
coverage to all regular employees. Coverage is available for the
employee and her/his eligible dependents. An employee electing medical
coverage has a choice among an HMO (Health Maintenance Organization),
a PPO (Preferred Provider Organization), or a hybrid of these.
The Institution and employee share in the cost of the coverage.
The Institution also provides group dental coverage at no cost to
the covered employee; dependent coverage is available at cost to
II. Group Medical
A. The coverage is through an insured
plan with Blue Cross Blue Shield of Massachusetts (BCBS).
III. Group Dental
1.The HMO is an "individual practice
association" (IPA) serving all of New England. Each member must
select a "primary care physician" (PCP) to coordinate her/his
care and for referral to specialists or affiliated hospitals.
Emergency treatment is covered when the member is outside the
service area. There are no deductibles or claim forms.
B. The level of coverage in any plan may be as:
Individual (employee) only; Employee plus Child(ren); Employee
plus Spouse; or Employee plus Spouse and Child(ren). The definition
of "Spouse" includes same-gender partners (requiring an affidavit).
2.The PPO provides both in-network and out-of-network
coverage. The provider network is Blue Cross national and
internation network. Each member may select any health care
provider, including specialists and hospitals. In-network
copayments are similar to the HMO. Out-of-network costs include
deductibles and copayments that are greater than in-network
out-of-pocket costs. However, there is a maximum annual out-of-pocket
cost to protect the member from large expenses.
3. "Access Blue" is a hybrid of the HMO and
PPO plans. It is very much like the HMO except no referral
is needed to any provider in the network. The coverage
areas is limited to most of Massachusetts.
C. The Institution and participating employee
share in the premium costs. This is true for any level of coverage
elected. The employee may elect to utilize the Institution's
"pre-tax payment" program, Premium Conversion Plan. This uses
pre-tax dollars to pay the employee's share of the premium.
D. For more information, including benefits and
definition of terms, refer to the appropriate plan booklet which
are available from Human Resources or BCBS.
A. The coverage is through an insured
plan with Delta Dental.
IV. Continuation of Coverage
1.The plan's contract is with over 96%
of the dentists in Massachusetts. However, services from any
dentist, including out-of-state, are covered. Participating
dentists have agreed to a maximum benefit allowance for each
procedure. For procedures requiring a copayment, the member
is responsible for only the deductible (if applicable) and her/his
share of the benefit. There is no "balance billing."
B. The level of coverage may be as an Individual
(employee) or Family. A same-gender partner may also be covered
(affidavit required). When electing Family coverage, this must
remain in effect until the next Open Enrollment period after one
year of participation.
2.For service from a non-participating dentist,
the same deductibles and copayments apply. However, since
the dentist does not have a contract with Delta Dental, the
member may be responsible for any amount in excess of the
maximum benefit allowance (balance billing).
C. The Institution pays the entire premium for
Individual coverage. The employee is responsible for the additional
premium to cover eligible dependents. The employee may elect
to utilize the Institution's "pre-tax payment" program, Premium
Conversion Program. This uses pre-tax dollars to pay the employee's
share of the premium.
D. Dental coverage includes four types of services:
diagnostic and preventive (no deductible); basic restorative;
major restorative; and child orthodontia.
E. For more information, including benefits and
definition of terms, refer to the Summary Plan Description which
is available from Human Resources.
A. Under the Consolidated Omnibus Reconciliation
Act of 1986 (COBRA), insured employees and their covered dependents
who have coverage in a group health plan may elect to continue
their coverage as follows:
V. Medicare and Supplemental Coverage
1.An employee covered by a group health
plan has the right to choose continuation of coverage if s/he
loses group health coverage because of a reduction in hours
of employment or the termination of employment (for reasons
other than gross misconduct), or because the employer has filed
for bankruptcy. COBRA requires that an insured employee be afforded
the opportunity to maintain continuation of coverage by paying
the full COBRA premium for up to 18 months. For provisions concerning
changes in status, including leaves of absence, see Definitions/Types
of Employment. If the employee is disabled within 60 days after
termination or reduction in hours, coverage may continue for
2.The spouse of an employee who is covered
by the Institution's group medical plan has the right to choose
continuation coverage if coverage is lost for any of the following
3.Dependent Children of an employee covered by
the Institution's group health plan have the right to continuation
of coverage if the coverage is lost for any of the following
- spouse's death;
- termination of spouse's employment (for
reasons other than gross misconduct) or reduction in spouse's
hours of employment; divorce or legal separation from
- spouse becomes eligible for Medicare;
- spouse's employer files for bankruptcy.
4.Except for loss of coverage due to the employee's
termination or reduction in hours, a qualified dependent electing
coverage under COBRA may continue the coverage by paying the
full COBRA premium for up to 36 months. Otherwise, continuation
is subject to the same limits of 18 and 29 months applicable
to the employee's rights.
- the death of a parent;
- the termination of a parent's employment
(for reasons other than gross misconduct) or reduction
in parent's hours of employment with the Institution;
- parent's divorce or legal separation;
- a parent becomes eligible for Medicare;
- the dependent ceases to be a "dependent
child" under the definition of the plan;
- the parent's employer files for bankruptcy.
5.Details of the rights and responsibilities
of a covered participant are given to each newly enrolled
employee (and her/his dependents). Notice of these same rights
and responsibilities is also given to qualified individuals
upon the occurrence of a qualifying event.
If either the employee and/or spouse is eligible for
Medicare and the employee still works for the Institution, the
employee and/or spouse has the option of enrolling
in Medicare Parts A and B, or continuing in the Institution's group
medical plan while in active eligible status.
you require assistance in the interpretation of this procedure,
please contact your Human Resources Representative.
Last updated: February 8, 2010