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Health Care

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Policy Information
  • Issue Date: July 1, 1997
  • Primary Contact: Director of Human Resources
  • Responsible Member of Directorate: President and Director
  • Responsible Office: Human Resources
Contents
Policy Information
Overview


Overview
I. General 
 
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 the employee. 

II. Group Medical 

A. The coverage is through an insured plan with Blue Cross Blue Shield of Massachusetts (BCBS). 
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. 

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.

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). 

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. 

III. Group Dental 
A. The coverage is through an insured plan with Delta Dental.
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." 

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). 

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.

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. 

IV. Continuation of Coverage 
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: 
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 29 months. 

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 reasons: 

  • 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;
  • spouse becomes eligible for Medicare; 
  • spouse's employer files for bankruptcy. 
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 reasons: 
  • 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. 
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.

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. 

V. Medicare and Supplemental Coverage 
 
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. 

VI. Retiree Participation 

Should you require assistance in the interpretation  of this procedure, please contact your Human Resources Representative.


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Last updated: December 4, 2013
 


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