YOUR BENEFITS
2011-2012 GUIDE TO TRAINING AND HEALTH BENEFITS
2011-2012 BENEFITS BOOK
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WELCOME Welcome to the first “Your Benefits” book from the SEIU Healthcare NW Training Partnership and Health Benefits Trust. This book is designed to serve as a complete guide to your training and health benefits. It features resources and information to make it easier to get the support you need. As a Home Care Aide, your training and health benefits are a critical part of the compensation you receive. Quality training and affordable health benefits provide the skills foundation and personal stability needed to help you deliver excellent care to your consumers and create future career pathways. You are the key to quality care in Washington’s long-term care system. Thank you for all you do to promote excellence in home care. Charissa Raynor Executive Director, Training Partnership and Health Benefits Trust
David Rolf Board Chair, Training Partnership and Health Benefits Trust President, SEIU Healthcare 775NW
MANAGE TRAINING / BENEFITS ONLINE www.myseiubenefits.org Enter your Username and Password below for easy reference USERNAME
PASSWORD
PRIMARY CARE DOCTOR / URGENT CARE CENTER Write your Doctor and nearest Urgent Care Center here for reference PRIMARY CARE DOCTOR NAME PHONE
URGENT CARE CENTER NAME AND ADDRESS
TRAINING DEADLINE Write your Training Deadline here for reference DAY
2
MONTH
MYSEIUBENEFITS.ORG
YEAR
HOURS NEEDED
TRAINING BASICS
Quick Start Guide
TRAINING STANDARDS
Your Benefits Book 4 If You Need Assistance 5 Multi-language Assistance 6 Quick Start: Training and Health 7 Access www.myseiubenefits.org 8 Home Care Aide Magazine Preview 10 Course Catalog Preview 11 Training Overview 13 How to Get the Most of Your Training 17 Interpretation 18 Online Continuing Education 19 How to Help Improve Future Classes 20
Training Standards Training Standards Overview 23 Training Standards Chart 24 Home Care Aide Categories 25 Support Contacts 26 Safety and Orientation 27
POLICIES
Training Policies Frequently Asked Questions 28 Classroom Policies 30 Reasonable Accommodation Policy 32
Health Benefits Health Benefits Overview 35 Participating Employers 36 Benefits Basics 37 2011-2012 Medical Plan Highlights 38 Urgent Care Centers 41 Dental and Vision Benefits 43
WELLNESS
Wellness Your Wellness 45 Health Benefits Quick Start 51
Health Benefits Policies
POLICIES
Frequently Asked Questions 52 Benefit Summaries 60 Group Health Options 61 Kaiser Permanente Health 68 Premera Dental 73 Willamette Dental 78 Questions and Appeals 80 Glossary 82 2011-2012 BENEFITS BOOK
HEALTH BENEFITS
ONTENTS
Training Basics
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QUICK REFER YOUR BENEFITS BOOK
One-Stop Resource for Training, Health Benefits To make it easier to understand your training and YOUR BENEFITS
health benefits, the Training Partnership and Health Benefits Trust put together the first “Your Benefits” book to guide you. These benefits are effective Aug. 1, 2011 through July 31, 2012.
GUIDE TO TRAIN ING AND
HEALT H BENEF ITS
Inside, you will find information about your benefits: Training Benefits • Training standards • Classroom policies • Glossary • Student resources
2012 BENEFITS BOOK
Health Benefits (For eligible Individual Providers or Home Care Aides covered through their employers) • • •
Eligibility Benefit summaries Wellness guide
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Where to find updates If there are changes to training standards or other information after the book is released, we will update “Your Benefits” book the following ways: Online - Updates will be available online at www.myseiubenefits.org/benefits YOUR Magazine - Updates will also be available three times a year in the new magazine for Home Care Aides, see Page 10 for more information.
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RENCE GUIDE IF YOU NEED ASSISTANCE
Individual Providers: If you need information about your training or benefits eligibility, log in to www.myseiubenefits.org first. If you cannot find the answer to your question, contact help below. Agency Providers: Contact your employer for support.
General Training and Health Benefits Support For fastest response: Fill out a Contact Form at www.myseiubenefits.org/contact Member Resource Center 1-866-371-3200 Mon.-Fri., 7 a.m.-7 p.m. The MRC is closed the following holidays: New Year’s Day Martin Luther King, Jr. Day Presidents’ Day Memorial Day
Independence Day Labor Day Thanksgiving Day after Thanksgiving Christmas Eve Day Christmas Day
See chart on Page 26 for who to contact for specific training-related questions.
Specific Health Benefits Support For answers to medical or dental plan questions, contact: Medical Plan Support Group Health Options www.ghc.org 1-888-901-4636 Mon.-Fri., 8 a.m.-5 p.m. Kaiser Permanente 1-800-813-2000 www.kp.org
Dental Plan Support Premera Blue Cross (Dental) 1-800-722-1471 www.premera.com Willamette Dental 1-800-359-6019 www.willamettedental.com
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QUICK REFERENCE GUIDE
Specific Training Support
QUICK REFER IF YOU NEED ASSISTANCE For Assistance Comuníquese con el Centro de Recursos para Miembros al 1-866-371-3200 si necesita asistencia para registrarse en su entrenameinto o para saber cuál es su elegibilidad para los beneficios de salud.
Hãy gọi Trung Tâm Nguồn Lực Thành Viên theo số 1-866-371-3200 nếu quý vị cần được trợ giúp trong việc lên lịch đào tạo hoặc tìm hiểu về điều kiện để nhận phúc lợi y tế. 훈련일정을 잡거나 건강혜택 자격 확인을 위해 도움이 필요하시면 회원지원센터 1-866-371-3200로 전화주세요. 如需在安排培训日程或了解您是否有资格获取保健福利方面获取协 助，请致电 1-866-371-3200 联系会员资源中心。
QUICK REFERENCE GUIDE
Если у Вас есть вопросы, связанные с определением расписания занятий, или относительно получения Вами пособия по нетрудоспособности, обращайтесь в Учебнометодический центр по телефону 1-866-371-3200.
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RENCE GUIDE QUICK START
Training Quick Start Individual Providers 1. Find Your Training Standards • There are different Home Care Aide standards depending on what category of care you provide. • Use the online Training Wizard – a tool to help you know which category applies to you – to find your individual training standards. Go to: www.myseiubenefits.org/wizard to complete the Wizard.
Jane Doe
STUDENT
1234567890
To report suspected abuse
or neglect
of a vulnerable adult, call toll free 2. Schedule Training Early 1-866-END-HARM • Locate or create your Username and Password (see Page 8). • Go online to www.myseiubenefits.org to log in to register for training or call the Member Resource Center at 1-866-371-3200.
3. Get Student ID Card in the Mail • Your Student ID card will be mailed to the mailing address you provided to your primary DSHS contact. If you don’t receive your ID card within 7-14 days of your hire date, fill out a Contact form at www.myseiubenefits.org/contact or call the Member Resource Center at 1-866-371-3200.
Agency Providers 1. Review chart on Page 26 to see who can support you.
1. Check your eligibility for health insurance benefits and enroll Individual Providers: Go online to www.myseiubenefits.org to log in to see your eligibility and enroll online, or call the Member Resource Center at 1-866-371-3200. Your eligibility for health insurance depends on the number of hours you work. Agency Providers: Contact your employer to see if you are eligible for health benefits through your employer. 2. Make an appointment with your primary care doctor Go to your health insurance provider’s website or contact them by phone (see contact info on Page 5) to find available doctors and other providers. See the Health Benefits section for more details. 2011-2012 BENEFITS BOOK
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QUICK REFERENCE GUIDE
Health Benefits Quick Start
QUICK REFER ACCESS MYSEIUBENEFITS.ORG
Manage Training and Benefits Easily Online The best way to manage your training and find your eligibility for benefits is through the www.myseiubenefits.org website. We have now improved the Username and Password process to make it easier for you to access the site.
How to Log in to the Website 1. Sign up for a First Time Username and Password First Time User
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Forgot Password or Username?
Note: We recommend you set up an email address to receive the quickest notifications, if you do not have one, you can get a free account at Gmail.com or Hotmail.com.
2. Verify Your Information
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RENCE GUIDE ACCESS MYSEIUBENEFITS.ORG
3. Create Your Username and Password
Note: You can choose any username or password you like
4. Confirm Your Username and Password
5. You’re Done!
Please write your Username and Password on Page 2 of this book to remember.
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QUICK REFERENCE GUIDE
Now You’re Ready to Log in to the Website!
QUICK REFER MAGAZINE
Coming in Fall 2011 - Home Care Aide Magazine As a community of Home Care Aides, you do important work and you have an important story to tell. You can help raise understanding of common challenges and experiences for Home Care Aides to help improve the profession. To help share knowledge and skills with the Home Care Aide community, a new magazine will be published three times a year and will focus on you and your work. Look for the first issue in the Fall of 2011.
Magazine Highlights
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Training and Health •
Best practices for Home Care Aides
•
Knowledge and skills builders
•
Student participation policies and news
•
Health Benefits beneficiaries policies and news
•
Your safety at work
Important Updates to “Your Benefits” book • Updates to “Your Benefits” book will be printed in the magazine as well as posted online; be sure to check your magazine for updates
Send us your story ideas! Do you have an interesting story to share of your successes or challenges as a Home Care Aide? Do you have a story about personal health and wellness? Do you have suggestions for stories or profiles you would like to see in the magazine? Send them to us! Go to www.myseiubenefits.org/stories to submit your story idea.
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RENCE GUIDE COURSE CATALOG
Course Catalog To help you find the Basic Training or Continuing Education courses you need, the Training Partnership will distribute a comprehensive course catalog. The course catalog, which will be released in August
SEIU Healthcare
NW Training Partnership
2011, will cover the Fall
-2011 CaTALOG
quarter of classes and will be an easy-to-use supplment to the online course catalog at www.myseiubenefits.org. Classes will be organized by region, date and title. The online course catalog will always have the most current information regarding courses. Please refer to the online catalog for updates.
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2011-2012 BENEFITS BOOK
TRAINING BASICS 12
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TRAINING BASICS
QUALITY TRAINING, QUALITY CARE The Training Partnership understands that adult learners bring a broad set of life experiences, education levels, and English language proficiency to the classroom. To meet that diversity, learning experiences are designed for you, adult students who bring previous knowledge and a passion for their work to
Vision Our vision is that every long-term care worker is a professional who has been trained rigorously, whose work is well respected and well compensated, who has meaningful opportunities for professional development and career growth, and who provides high quality care.
class. The focus is on practical skill development that will help you to do your job.
What can you expect from Basic Training courses? •
As a student, you can expect to meet an instructor with direct care experience who is passionate about supporting Home Care Aides in their professional growth.
•
You can expect to meet and work with other students in small group exercises, activities, role plays and games.
•
You can expect opportunities to learn using different methods like watching video clips, completing written activities, and presenting to others.
•
‘‘
You can expect to learn specific skills, see them demonstrated and then have a chance to demonstrate the skill yourself.
The classes were very helpful and they gave me new, healthier ways to deal with challenges at work. – Jasmine, Training Partnership Student
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You can expect to use a student guide during class which you can keep as a future resource.
•
TRAINING BASICS
•
You can expect to be asked
Mission Our mission is to train and develop professional long-term care workers to deliver high quality care.
what you think, to share what you know, to contribute to discussion, and to answer questions.
What can you expect from Continuing Education courses? •
You can expect options in course formats, including in-person and online learning choices.
•
You can expect choice in the style courses are taught, from expert lectures to group discussions.
•
You can expect variety in subjects, from broad overviews to in-depth explorations on specific topics.
•
You can expect instructors who are not only professional, but have knowledge or expertise in the area they are teaching.
What characterizes the work of the Training Partnership? There are several themes that infuse the courses, actions, and work of the Training Partnership. They are: •
Dignity of the work and the Home Care Aides who do the work;
•
Dignity of the consumer whose preferences, individuality, and needs must be respected;
•
Empowerment of the Home Care Aide to improve their lives and the lives of consumers;
•
Professionalism of the workforce; and
•
Cultural competency and inclusiveness to honor differences.
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TRAINING BASICS
HOW TO GET THE MOST OF YOUR TRAINING Use the Training Wizard Start with the easy online Training Wizard to find the training you need. Go to: www.myseiubenefits.org/wizard to complete the Wizard.
Register Early for Training If you need Basic Training, we encourage you to register for your classes within the first 30 days of hire to get the best choice of class options. If you need Continuing Education (CE) classes, register as early as possible to get the best choice of class options before your deadline.
Take Online Learning for Continuing Education Credits Online Continuing Education courses are an easy and convenient way to get the CE hours you need as a Home Care Aide. You can view available courses, take classes and view your credits all from your computer – 24/7.
Go Online for Fastest Service and Support The www.myseiubenefits.org web portal is your comprehensive resource for available classes, your current training status, benefits eligibility and much more. Log in to the portal first to get the answers you need. Instructions to getting a username and password are on Page 8.
Update Your Contact Info Ensure you are receiving the most current information about your training by updating your contact information with your employer. If are you an Individual Provider, update your information with your primary DSHS contact. If you are
‘‘
an Agency Provider, update your information with your employer.
The class on mental health really helped me understand the issue better and gave me tools. I feel more prepared to help my client with mental health issues now. – Marcos, Training Partnership Student
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INTERPRETATION Individual Providers: The Community Interpretation option is available to you.
Agency Providers: Indicate to the person who registers you for class that you will be bringing an interpreter.
Community Interpretation The Training Partnership values the diversity of Home Care Aides. Basic Training courses are offered in English, Cantonese, Spanish, Russian, Korean, and Vietnamese. For those students who speak another primary language and are unable to take courses in English, we offer a Community Interpretation option.
Steps to Register for Community Interpretation 1. Notify the Training Partnership: At the time of course registration, tell us if you will be bringing someone with you to serve as your interpreter. 2. Reserve Space: If you are bringing someone to interpret, you are responsible for telling them when and where the class will be held and for reserving space for them in the class. 3. Orientation: If you have a friend or family member interpret for you, we offer a tip sheet and other information that will help prepare your interpreter to assist you in class. Additional information about the Community Interpretation Orientation can be found at www.myseiubenefits.org/training/interpretation
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TRAINING BASICS
ONLINE CONTINUING EDUCATION As of August 2011, there are 10 Continuing Education (CE) classes you can take online by going to www.myseiubenefits.org. More classes will be added throughout the year. With online classes you pick the time and topics that work for you. You can see the available courses, register and access courses, receive credit, and navigate help information – all online and all 24 hours a day! Each online course takes about one hour to complete, which may vary depending on learning style, material covered and Internet
‘‘
I loved being able to take the Multiple Sclerosis module online. I learned a lot and I could do it at home! – Abdul, Training Partnership Student
connection speed.
Online Continuing Education Classes as of August 2011 Best Practices for the Professional Home Care Aide Traumatic Brain Injury
An Introduction to Mental Illness Multiple Sclerosis
Body Mechanics
An Introduction to Developmental Disabilities
Infection Control: Promoting Health and Well-Being
An Introduction to Physical Disabilities
Better Health through Nutritious Cooking
An Introduction to Dementia
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HELP IMPROVE FUTURE CLASSES Participate in strengthening future classes – a call to action
Individual Providers: Use course reviews and the Wiki below.
Agency Providers: Use course reviews to provide feedback.
Course Reviews All Home Care Aides are encouraged to complete a course review online at
Course Reviews How do you submit a course review? Course reviews are available on your student profile. Log in with your username and password, select “manage my training,” and under the completed training box, click “review now.”
www.myseiubenefits.org after each course you take. Course reviews are allow the Training Partnership to make adjustments in course content and instructors. Your feedback is taken seriously. How do you submit a course review? Course reviews are available on your student profile. Log in with your username and password, select manage my training, and under the completed training box, click “review now.”
Wiki The Training Partnership welcomes the participation of home care aides, consumers, instructors and employers in the process of curriculum development. You’re invited to give your feedback on existing courses created by the Training Partnership as well as give suggestions for future courses by using the wiki. The wiki is a website which allows you to give your input. You can comment on current classes, suggest additional topics and subjects, and even provide comments on classes that in the development stages. How do you access the wiki? Visit http://trainingpartnership.pbworks.com •
If you have logged in previously, your username is your email address.
•
If you’ve never visited the wiki before, you can request access and in the next two business days, you’ll receive a response email with a link to activate your account.
Use the comment box at the bottom of any page to enter your suggestions on how to make training even better. 20
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TRAINING BASICS
Volunteer Auditor Program Have you ever wished you could register for a class that is not required for you to take? The Training Partnership is excited to announce a new program designed to help increase the feedback from our students about courses while giving you access to more classes. The Volunteer Auditor Program is designed for students who want to volunteer to sit in on classes around the state. In exchange for feedback on curriculum, instructors and classroom spaces, students can take additional classes which either are not required for them, or exceed their training needs. If you are interested in becoming a Volunteer Auditor, the Training Partnership will orient you to our expectations for observing courses and what to look for. Once you have been oriented, you can register for courses and participate like a typical student. After the class you go online to complete a survey and share your experience with the Training Partnership. Courses will appear in your training record as audited. Auditing can only happen once you have met your training standards for that year. If you are interested in becoming a student auditor, contact the Training Partnership at our Contact form www.myseiubenefits.org/contact. We anticipate this program will start in the fall of 2011.
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TRAINING STANDARDS 22
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www.yes1163.com
TRAINING STANDARDS
TRAINING STANDARDS The recent budget passed by the state legislature resulted in funding cuts that impact the Training Partnership. The legislation suspended the higher training standards of Initiative 1029, which set training levels for Home Care Aides. See a complete list of training standards on the following page.
Basic Training Curriculum As of July 1, 2011, Initiative 1029 – which increased basic training standards to a maximum of 75 hours – was suspended. The result was going back to previous standards which capped basic training hours at 28 and up to six hours of Safety and Orientation. In response, the Training Partnership has revised its basic training curriculum to address the new hours requirement. This revised curriculum, approved on
Initiative 1163 Initiative 1163 will appear on the ballot in November. If the initiative passes it will reinstate the higher-quality training and certification standards for most new Home Care Aides (exempting those caring for a parent or child) on Dec. 8, 2011. Home Care Aides who have already taken Basic Training will not need to take the higher quality training. For more on I-1163, visit www.yes1163.com.org
July 14, 2011 as an ADSA alternate basic training curriculum, is called Accelerated Basic Training.
Continuing Education The Continuing Education requirement remains 10 hours per year. The Training Partnership provides quality Continuing Education (CE) classes that help Home Care Aides (HCA) maintain skills in the profession and provide knowledge to reach the highest standards of practice. CE classes are widely available at 150 sites across the state and 10 classes are available online all day, every day. The classes cover a broad range of subjects. You choose the ones that are most suited to your interests and the consumers you serve. 2011-2012 BENEFITS BOOK
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Not Required
Not Required
Childcare IP (DDD)
Respite Worker (DDD)
Within 120 days of employment Not Required Not Required Required if performing a Nurse Delegated Task
Within 14 days of employment
Within 14 days of employment
Within 14 days of employment
Not Required
Not Required
Not Required
Within 180 days of employment
Not Required
Not Required
Not Required
Not Required
Within 180 days of employment Not Required
Not Required
10 hours/year beginning the year after completing ABT or MFOC
10 hours/year beginning the year after completing ABT or MFOC
10 hours/year beginning the year after completing ABT or MFOC
10 hours/year beginning the year after completing ABT or MFOC
Not Required
Not Required
Within 120 days of employment
Not Required
Not Required
Within 120 days of employment
Optional, consult with your employer
Not Required
Not Required
Within 120 days of employment
Within 120 days of employment
Within 120 days of employment
Within 120 days of employment
Continuing Education 10 hours by 12/31/11
Continuing Education
*If hired before 6/15/11, please refer to your training profile or to the Training Wizard on www.myseiubenefits.org/wizard for the most current requirement. **If you work for more than one consumer, you may have more than one basic training requirement. Please check with your employer.
Not Required
Parent DD IP (DDD)
Basic Training** Accelerated Basic Modified Fundamentals Parent Provider Training (ABT) OR of Caregiving (MFOC) OR Class 6 hours
Within 14 days of employment
Within 14 days of employment
Within 14 days of employment
Credentialed IP
Not Required
Not Required
Provided by Employer
Credentialed AP
Parent Individual Provider (HCS/AAA)
Within 14 days of employment
Within 14 days of employment
Individual Provider (IP)
Not Required
Safety Training 4 Hours
Provided by Employer
Orientation 2 Hours
Agency Provider (AP)
Hired after June 15, 2011*
Orientation and Safety
TRAINING STANDARDS
HOME CARE AIDE CATEGORIES The Training Partnership provides training to a variety of Home Care Aides. The chart below describes the different categories of HCAs Provide care to a consumer living in his or her home.
Agency Provider (AP)
Provide care to a consumer living in his or her home. Employed by a private homecare agency.
Individual Provider (IP)
Provide care to a consumer living in his or her home. Employer of record is DSHS.
Credentialed Agency Provider
This is an AP with a current healthcare credential as a Registered Nurse (RN), Licensed Practical Nurse (LPN), Nursing Assistant Certified (NAC), Physical Therapist, Occupational Therapist or Medicare-Certified Home Health Aide.
Credentialed Individual Provider
This is an IP with a current healthcare credential as a Registered Nurse (RN), Licensed Practical Nurse (LPN), Nursing Assistant Certified (NAC), Physical Therapist, Occupational Therapist or Medicare-Certified Home Health Aide.
Parent Individual Provider (HCS/AAA)
This is an IP who provides care to his/her own adult child and contracted through Home and Community Services (HCS) and/or an Area Agency on Aging (AAA).
Parent DD Individual Provider (DDD)
This is an IP who provides care to his/her own adult child with a developmental disability and is contracted through the Department of Developmental Disabilities (DDD).
Childcare Individual Provider (DDD)
This is an IP who provides care to a consumer under the age of 18 and is contracted through the Department of Developmental Disabilities (DDD).
Respite Workers (DDD)
This is an IP who provides short, intermittent relief for person normally providing care to waiver individuals.
2011-2012 BENEFITS BOOK
TRAINING STANDARDS
Home Care Aide (HCA)
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WHO TO CONTACT FOR TRAINING SUPPORT Agency Providers individual providers
Class registration and rescheduling
(Visiting Nurse Homecare, Senior Life Resources, Oly CAP, CoastalCAP, Full Life)
Agency Providers (Addus, Chesterfield, KWA, ResCare, SeaMar, Amicable)
Agency Providers (Catholic Community Services, CDM)
Website or MRC
Website or MRC
Your Employer
Your Employer
How to complete your Website or MRC training
Website or MRC
Your Employer
Your Employer
Username and Website or MRC Password assistance
Website or MRC
Website, MRC or Employer
Your Employer
Confirmation Code
Website or MRC
Website or MRC
MRC
Your Employer
Requesting a student ID
Website or MRC
Website or MRC
MRC
Your Employer
Requesting a certificate
Website or MRC
Website or MRC
MRC
Your Employer
Confirming class schedule
Website or MRC
Website or MRC
Website, MRC or Employer
Your Employer
Training requirement Primary DSHS Contact Your Employer and deadlines
Your Employer
Your Employer
Questions about payment
Primary DSHS Contact Your Employer
Your Employer
Your Employer
Change of address
Primary DSHS Contact Your Employer
Your Employer
Your Employer
Change in training standards due to change in employment status
Primary DSHS Contact Your Employer
Your Employer
Your Employer
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SAFETY AND ORIENTATION For Individual Providers If you are in a category that requires either Safety or Orientation training (or The kit contains the following: 1. Instructions on “How to Complete and Receive Credit for Safety and/or Orientation.” 2. Three DVDs: Orientation, Safety Training Part 1, Safety Training Part 2. 3. An activity sheet titled, “Safety and Orientation Self-Study Extension.” 4. Supplemental information titled, “Orientation & Safety – A Reference Tool for Individual Providers.” SEIU HEAL THCARE N Th
W
e Training TRAINING Partners PARTNER hip trains care worke and deve SHIP rs to deliv lops profes er high qu and peop sional lon ality care le with dis g-term and supp abilities. ort to old er adults
Your deadline for completing Safety and/or Orientation is
14 days from your date of hire. If you did not receive the Safety and Orientation Kit, notify your DSHS contact immediately or contact the
SAFETY & ORIENTAT ION
Training Partnership at www.myseiubenefits.org/contact
WWW.MY
SEIUBEN
EFITS.OR
G
635 ANDO
VER PARK
WEST SU
ITE 200, TU
KWILA, WA
98188
SEI U H E T R A IN INAGL T H C A R E N W PA R T N E R S H IP
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TRAINING STANDARDS
both) you should have received a kit at the time of hiring or contracting.
FREQUENTLY ASKED QUESTIONS 1. What is www.myseiubenefits.org?
I have a question about The website www.myseiubenefits.org is wages for training? where you can read important Contact your employer or announcements from the your DSHS case manager. Training Partnership, learn The Training Partnership about our different programs cannot answer questions and ask questions. On the regarding wages. website, you can register for classes, see your training history and track your progress. You can also take online Continuing Education classes by going to this website.
2. How do I get my training certificate? Your Basic Training certificate should be mailed to you within two weeks from the day you complete all hours of your required basic training. You should receive your Continuing Education certificate within one month following the day you complete all hours of your required continuing education credits. Refer to the Support chart on Page 26 if you need assistance. 3. How do I get a Student ID? Your Student ID card will be mailed to the mailing address you provided to your employer (DSHS or Agency) within 7-14 days of your hire date. If you do not receive your ID card, please check with your employer to make sure your address is correct. Replacement cards can take up to four weeks to receive. For fastest class check in, bring your Student ID. Bring a driver’s license, passport, or other legal identification to class. Refer to the Support chart on Page 26 if you need assistance. 4. How do I change my address with the Training Partnership? Ensure you are receiving the most current information about your training by updating your contact information with your employer. If are you an Individual Provider, update your information with your primary DSHS contact. If you are an Agency Provider, update your information with your employer.
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FREQUENTLY ASKED QUESTIONS 5. How do I log in to www.myseiubenefits.org? There is now a new and improved easier process for logging in to the website. Follow the instructions on Page 8 to log in. 6. I have a question about wages for training. Contact your employer or your DSHS contact. The Training Partnership cannot answer questions regarding wages 7. I arrived to class and I am not on the roster, what do I do? Only registered students and interpreters can attend Training Partnership classes. If you are not on the roster, you will need to reschedule your class.
Your feedback is very important to us and we want to know about your class experience with the Training Partnership. You can complete a course review after attending a class by going to www.myseiubenefits.org. For more information on submitting feedback, see Page 20.
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POLICIES
8. How do I provide feedback about a class?
CLASSROOM POLICIES At the Training Partnership we know you have taken your valuable time to come to class. To support each other and ensure everyone can get the most out of each class, we have created the following polices in order to create a successful learning environment.
Class Registration •
Students need to be registered for class and on the class roster in order to take a class.
•
If you have not previously registered for a class, you will not be able to take the class.
•
If you are not on the class roster, you will not get credit for the class.
Only Registered Students and Interpreters are Allowed in Class •
The only people allowed in class are registered students and registered interpreters.
•
Students may not bring consumers, children, or any other visitors to class.
Classes Start On Time •
If you arrive to class after the start time, you will be considered late, you will need to reschedule your class.
•
You should arrive to class 15 minutes before the start time to avoid being late.
Bring Picture ID
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•
Students are expected to show valid picture ID to sign in for class.
•
You should bring your Training Partnership ID if you have one.
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CLASSROOM POLICIES Student Participation •
Students are expected to fully participate in the learning experience.
•
Personal phone calls or other personal matters should be taken care of during breaks.
Class Cancellation •
A student will need to cancel class registration at least 72 hours in advance of the class time.
•
If the Training Partnership has to cancel a class, a notification of the class cancellation will be sent to you based on the communication preference in your online profile. The Training Partnership will work with you to reschedule the class.
•
POLICIES
No Shows Cancelling late or not attending class results in a no show. After two no shows, you will have to pay a $25 no-show fee to access training.
Appeals Process •
If you wish to appeal the $25 “no show” fee because you believe you had a good reason for not attending the class you must file an appeal.
•
The appeal must be filed on an appeal form that is available at www.myseiubenefits.org.
Inclement Weather •
If the Training Partnership has to cancel a class due to inclement weather, a notification of the class cancellation will be sent based on the communication preference in your profile. The Training Partnership will work with you to reschedule the class.
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REASONABLE ACCOMMODATION POLICY Policy on Reasonable Accommodation of Students with Disabilities The SEIU Healthcare NW Training Partnership (“Training Partnership”) admits students regardless of race, color, national origin, ethnic origin, gender, age, disability and sexual orientation to all the rights, privileges, programs, and activities generally accorded or made available to students by the Training Partnership. It does not discriminate on the basis of race, color, national origin, ethnic origin, gender, age, disability and sexual orientation in administration of its training and educational policies, admissions policies, scholarship and loan programs, and other Training Partnership administered programs.
What is Reasonable Accommodation? Reasonable accommodation means modifying or adjusting practices, procedures, policies, educational services and delivery, or the training environment so that a student with a disability can enjoy equal educational opportunity, so long as (1) there is sufficient medical evidence establishing a relationship between the disability and the need addressed by the specific accommodation; and (2) it does not impose an undue hardship on the Training Partnership.
Students with disabilities have the right to request and receive reasonable accommodation so that students may have the opportunity to take full advantage of the Training Partnership’s programs and activities.
When is a person regarded as having a disability? For purposes of accommodation, a person is regarded as having a disability if he or she has a sensory, mental, or physical impairment that is medically cognizable or diagnosable or exists as a record or history or is perceived to exist.
What is Reasonable Accommodation? Reasonable accommodation means modifying or adjusting practices, procedures, policies, educational services and delivery, or the training environment so that a student with a disability can enjoy equal educational opportunity, so long as (1) there is sufficient medical evidence establishing a relationship between the disability and the need addressed by the specific accommodation; and (2) it does not impose an undue hardship on the Training Partnership.
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REASONABLE ACCOMMODATION POLICY What is Undue hardship? Undue hardship means, among other things, an excessively costly, extensive, substantial or disruptive modification or one that would fundamentally alter the nature or operations of the Training Partnership or its programs.
Overview of Accommodation Process To request reasonable accommodation, a student with a disability should request accommodation from the Training Partnership by completing the “ADA Request Form� found at www.myseiubenefits.org or by calling the Member Resource Center. Once the request is received by the Training Partnership, the Accommodation process will start, during which the student will be asked to provide current documentation of his or her disability, the functional limita-
POLICIES
tions resulting from the disability and recommendations for specific accommodations. As part of the Accommodation process, the Training Partnership will confer with the student to identify appropriate and reasonable accommodations that may be warranted under the particular circumstances. The Training Partnership has the right to establish qualifications and other essential standards and requirements for its courses, programs, activities and services. All students are expected to meet these essential qualifications, standards, and requirements with or without reasonable accommodations. More detailed information on the Accommodation process can be found at www.myseiubenefits.org.
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HEALTH BENEFITS 34
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AFFORDABLE HEALTH BENEFITS FOR YOU For eligible Individual Providers and Agency Providers, the Health Benefits Trust is a nonprofit organization providing affordable health coverage focused on keeping you healthy. The health benefits offered by the Health Benefits Trust are part of a community of care that starts with the wellness of you, the Home Care Aide.
2011-2012 Benefits Plan The Health Benefits Trust negotiated the 2011-2012 benefits – that took effect on Aug. 1, 2011 – to fulfill the following goals: • • •
Emphasis on preventive care to encourage wellness Increased participation in health risk assessments Higher use of urgent care facilities in urgent situations that don’t
HEALTH BENEFITS BASICS
•
Low out-of-pocket costs for Home Care Aides
require emergency-room care • •
Encouraging lower-cost prescriptions through mail order services Encouraging use of in-network providers
The 2011-2012 benefits plan accomplishes those goals and allows for the continuation of affordable, quality benefits for all eligible Home Care Aides.
How to Enroll Individual Providers: You can enroll by logging in to www.myseiubenefits.org and by filling out the enrollment form. Agency Providers: Contact your employer for enrollment information. Call the Member Resource Center toll-free at 1-866-371-3200 to get answers to your questions about eligibility for benefits.
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Participating Employers Washington employers whose employees are eligible for benefits through the Health Benefits Trust. NOTE: This list may change, check with your employer to verify participation. AAA Residential Services Addus Healthcare Amicable Healthcare Catholic Community Services CDM Chesterfield Healthcare Full Life Home Care Services of Montana KWA Lower Columbia Community Action Council
Oly CAP Coastal CAP Senior Life Resources Northwest State of Washington (employer of record) Visiting Nurse Home Care NOTE: ResCare is in the final stages of preparation to join the Health Benefits Trust.
Health Plan Partners We partner with the following health insurance providers to provide benefits for eligible Home Care Aides.
Group Health Options Offering you a health plan that gives you access to coordinated care and coverage that makes staying healthy easy.
Kaiser Permanente A large national health insurer, Kaiser provides coordinated care and innovative health care programs.
Premera Blue Cross (Dental) Premera offers dental insurance to Health Benefits Trust beneficiaries.
Willamette Dental Group Willamette is a managed dental program that provides general and specialized dental services to patients all over Washington and Oregon. 36
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BENEFITS BASICS Home Care Aides get the following comprehensive benefits through the Health Benefits Trust:
Medical Nobody ever plans to get sick, but the Health Benefits Trust has you covered. Depending on where you live, your medical, vision and prescription drug coverage will be provided by Group Health Options or Kaiser Permanente. You pay very little out-of-pocket for the following services: • • • • • • •
Doctor office visits In-patient hospitalization X-rays and diagnostic imaging Laboratory services Mental health Hearing exams Chiropractor visits
• • • • • •
Acupuncture Mammograms Allergy shots and other injections Routine immunizations Rehabilitative therapies Maternity services
Vision •
Hardware, such as glasses and contacts
HEALTH BENEFITS BASICS
•
Routine exams
Prescription Drugs • •
Generic drugs Brand-name drugs
Dental The Health Benefits Trust helps with routine dental care as well as dental emergencies. Dental benefits are provided by Premera Blue Cross Dental and Willamette Dental. Preventive care: There is no annual deductible for preventive procedures. Covered procedures include check-ups, cleanings and X-rays. Basic procedures: Covered procedures include fillings, oral surgery, periodontics (gum disease) and endodontics (root canals). Major procedures: Covered procedures
HOW MUCH DOES IT COST? The Health Benefits Trust works hard to minimize the amount you pay out-of-pocket for your healthcare. You pay $25 per month toward the premium for medical/prescription/vision and dental coverage. You cannot enroll for only medical or only dental coverage.
include crowns, dentures and bridges. 2011-2012 BENEFITS BOOK
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2011-2012 Medical Plan Highlights Thanks to effective organizing by Home Care Aides and strong negotiating by the Health Benefits Trust, the health benefits Home Care Aides will receive through July 31, 2012, remain largely unchanged. Although insurance premiums are increasing overall, the Home Care Aide cost share will remain the same at $25 per month. The level of insurance coverage provided remains the same, with a few exceptions that encourage good use of Health Benefits Trust resources:
Premium Cost Share Unchanged The premium cost share for Home Care Aides will remain the same at $25 per month.
EMERGENCY ROOM Whenever you use the Emergency Room, you will pay a $200 copay regardless of facility. However, if you are admitted to the hospital as a result of your visit to the ER, the $200 will not be charged. As a better alternative to the Emergency Room in most situations, Urgent Care is available and your copay will be just $10 for Group Health and $30 for Kaiser.
IN-NETWORK PROVIDERS You do not have to pay as much when accessing an in-network group of providers and facilities, including purchasing your prescription drugs. •
In-network services continue to have a $0 annual deductible and $10 office visit copay. However, preventive care now is paid in full with no copay.
•
If you choose to access care out-of-network, your annual deductible will increase from $200 to $500.
Understanding Health Insurance Terms Copay The amount you will pay at the time of your visit. Deductible The amount that you pay for covered services before the plan begins paying in a given year. You need only to satisfy your deductible once in a calendar year.
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In-network You don’t have to pay as much when you use this network of providers. Out-of-network A broader network of providers where you may access care but your out of pocket expenses will be higher than with in-network providers.
Health Profile = $25 for you PRESCRIPTION DRUGS The prescription drug copays are increasing slightly. However, by using mail-order service to receive your prescriptions, you will now receive a discount on your prescription copay.
Fill out your Health Profile, offered by Group Health Options or the Total Health Assessment, offered by Kaiser Permanente and the Health Benefits Trust will send you a check for $25! Good for your health, good for your wallet.
HEALTHCARE REFORM CHANGES As a result of Healthcare Reform, your coverage will be improved in the following ways: •
There is no longer a lifetime maximum cap of benefits.
•
There are no longer lifetime benefit limits for essential benefits.
2011-2012 PLAN HIGHLIGHTS AT A GLANCE IN-NETWORK
OUT-OF-NETWORK
Preventive Care
Covered In Full
Covered in full up to $300
Covered In Full
$500 deduct, 80% Covered
Group Health Options
$10
$10 copay, deductible and coinsurance apply
Kaiser
$30
No out-of-network allowed
Generic
$15 copay
$20 copay
30 day supply; For Kaiser, no out-ofnetwork allowed
Brand
$30 copay
$35 copay
30 day supply: For Kaiser, no out-ofnetwork allowed
Group Health Options Mail-order
$30 Generic $75 Brand
Not applicable
90-day supply
Kaiser Mail-order
$30 Generic $60 Brand
Not applicable
90-day supply
$200 copay
$200 copay
Waived if admitted
Group Health Options
$0
$500
Kaiser
$0
Not allowed
Mammograms
NOTES
Routine mammograms
Urgent Care
Prescription Drugs
Emergency Room Out-of-Network Deductible
No out-of-network allowed
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HEALTH BENEFITS BASICS
BENEFIT
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Group Health Options: Urgent Care Centers Seven Group Health medical centers have Urgent Care Centers, most with evening, weekend, and holiday hours. Urgent Care Centers at the Bellevue Medical Center and Capitol Hill Campus in Seattle are open 24 hours a day, seven days a week. Use the Group Health Options Provider Directory www.ghc.org to find urgent care providers in other areas. (Select “All Specialists,” then select “Urgent Care” from the drop-down list.)
Silverdale Medical Center Monday-Friday 8 a.m.-5 p.m. 10452 Silverdale Way N.W. Silverdale, WA 98383 360-307-7300
Everett Medical Center Monday-Friday 8 a.m.-5 p.m. 2930 Maple St. Everett, WA 98201 425-261-1500
Riverfront Medical Center Monday-Friday 8 a.m.-5 p.m. 322 W. North River Drive Spokane, WA 99201 509-324-6464
Olympia Medical Center Monday-Friday 8 a.m.-5 p.m. 700 Lilly Road N.E. Olympia, WA 98506 360-923-7000
Tacoma Medical Center Monday-Friday 8 a.m.-5 p.m. 209 Martin Luther King Jr. Way Tacoma, WA 98405 253-596-3300
Capitol Hill Campus Monday-Friday 8 a.m.-5 p.m. 201 16th Ave. E. Seattle, WA 98112 206-326-3000
HEALTH BENEFITS BASICS
Bellevue Medical Center Monday-Friday 8 a.m.-5 p.m. 11511 N.E. 10th St. Bellevue, WA 98004 425-502-3000
URGENT CARE SAVES YOU MONEY The out-of-pocket cost for a trip to the emergency room is $200 (waived if you are admitted to the hospital) vs. just $10 for a trip to Urgent Care with Group Health Options, and $30 with Kaiser. 2011-2012 BENEFITS BOOK
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Dental Benefits Healthy teeth and gums are a critical part of
Did You Know?
your overall health. That’s why comprehensive
The American Dental Association says healthy gums are linked to a healthy heart? Another reason to visit your dentist regularly.
dental benefits are included in the coverage you receive through the Health Benefits Trust. To keep your teeth healthy, your dental benefits include at no additional cost to you for in-network services: •
Routine exams
•
Regular cleanings
•
X-rays
•
Gum care
•
Fillings
Depending on your plan, a portion of the cost of the following procedures may also be covered: Crowns, inlays
•
Dentures
•
Implants
HEALTH BENEFITS BASICS
•
To take the best care of your teeth and gums, you should see your dentist every six months for a complete exam and cleaning.
Vision Benefits Keeping your eyes healthy and keeping optical prescriptions updated are also important to your overall health and well being. Vision benefits through the Health Benefits Trust are an affordable way to ensure your sight is protected.
Did You Know? As part of a complete wellness plan, everyone should have regular eye exams, whether or not you’re having any noticeable signs of problems.
• For a $10 copay per visit, you receive routine vision care. • Every two years you receive $200 worth of optical supplies, including contact lenses and frames.
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WELLNESS 44
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YOUR WELLNESS Working Together To Keep You Healthy As a Home Care Aide, you know how important it is to stay healthy. Through the benefits you receive through the Health Benefits Trust, you receive excellent health, dental and vision benefits at a low cost. To ensure that health care for Home Care Aides continues for years to come, there are three things we all need to do: • • •
Keep ourselves healthy Keep out-of-pocket costs low Help control health care costs so we do not have to pay more next year
Four Steps to Better Health There are four key ways you can maximize your benefits for better health: •
Making your first primary care appointment
•
Using urgent care vs. the emergency room
•
Managing prescriptions
•
Completing a Health Profile or Assessment
Follow the steps below and on the following pages to get started.
WELLNESS
Healthy Home Care Aide
URGENT CARE
URGENT CARE
URGENT CARE See a Primary Care Doctor
Health Profile or Assessment
Find Urgent Care Centers
Manage Your URGENT CARE Prescriptions
Find a doctor, set up your first visit
Fill out an easy online quiz
Locate the centers near you
Transfer to Kaiser or Group Health Options
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1
See a Primary Care Doctor
One of the most important things to do is to select a primary care doctor and set up a first visit. A strong relationship with your primary care doctor (also known as your primary care provider) is at the heart of your care.
How to Select Your Primary Care Doctor Go Online: Use the provider directory at www.ghc.org URGENT CAREor www.kp.org to find a personal physician who’s a good match for you. or Call: Group Health Options Customer Service at 1-888-901-4636 Kaiser Permanente Customer Service at 1-800-813-2000
Make an Initial Primary Care Appointment = Earn $10! Establishing a relationship with your primary care provider is important to your health. If you obtain a preventive care/wellness visit from your primary care doctor within the first three months of your coverage effective date, the Health Benefits Trust will pay you $10. You may only receive the benefit once.
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DID YOU KNOW? Your out-of-pocket expenses are much less when you use in-network providers. Assuming you have four office visits this year, your out-of-pocket expenses using a Group Health provider would be $40 vs. $500 or more with an out-of-network provider.
2
Complete a Health Profile or Assessment How Healthy are You? The Health Profile and Total Health Assessment will help you find out! •
What are your daily eating habits?
•
How often do you exercise?
•
How often do you drink alcohol?
URGENT to CARE Find out how the answers questions like these affect your health. Your Health Profile or Total Health Assessment are online quizzes to help you and your doctor take better control of your health. Filling out a Health Profile is a key step on the path to better health.
Fill out a Health Profile or Assessment, Receive $25! Beginning Aug. 1, 2011, Home Care Aides who complete a Group Health Options Health Profile or Kaiser Permanente Total Health Assessment will receive a $25 check from the Health Benefits Trust. You will receive a check within 6–8 weeks of submitting your profile.
WELLNESS
Register for MyGroupHealth for Members at ghc.org To access the Health Profile, you need to upgrade your MyGroupHealth account so you have access to online services. To register, visit www.ghc.org or call Website Customer Service at 1-888-874-1620.
Register for Kaiser Online Access Using Kaiser online access, you can fill out your Total Health Assessment. Register at www.kp.org 2011-2012 BENEFITS BOOK
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3
Locate Closest Urgent Care Center
It is important to locate your Urgent Care Center in
URGENT CARE
advance because in the event you need urgent care, it is often a difficult time to look for an Urgent Care Center.
When to Use Urgent Care vs. Emergency Room Here are some examples of when to use urgent care or the emergency room. This is not intended as a complete list. URGENT CARE - $10 per visit Allergies Asthma Attack (Minor) Cold, Flu, Fever Cough Dizziness Fractures Nausea Minor Burns Minor Cuts/Lacerations Sore Throat Sprains Stitches
DID YOU KNOW? Urgent Care is a much more affordable option for Home Care Aides through the Health Benefits Trust. The out-of-pocket cost for a trip to the emergency room is $200 (waived if you are admitted to the hospital) vs. just $10 for a trip to Urgent Care with Group Health Options and $30 with Kaiser. 48
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EMERGENCY ROOM - $200 per visit (waived if admitted) Chest Pain Compound Fractures (Bone Visible) High Fever Ingestion of Poison Major Head Injury Seizures Severe Asthma Attack Severe Burns Shock Uncontrollable Bleeding
Where to Find Urgent Care GROUP HEALTH OPTIONS: Seven Group Health medical clinics have Urgent Care Centers, most with evening, weekend, and holiday hours. Use the Provider Directory online to find urgent care providers in other areas. See Page 41 for a list of centers. KAISER: Find an Urgent Care Center at www.kp.org
Manage Your Prescriptions
4
Your prescriptions are a big part of your health benefits. Make the most of them by managing them wisely.
Transfer Prescriptions If you have existing prescriptions, have them transferred to Group Health Options or Kaiser Permanente to receive best benefit from your coverage.
URGENT CARE
Mail Order Prescriptions Using mail order prescriptions saves money and saves time. Getting your prescriptions by mail is free and for Group Health Options members you get a discount of up to $5 per prescription.
How to Transfer Your Prescription Group Health Options: Go online to www.ghc.org to transfer your prescription or call Customer Service at 1-888-901-4636. Kaiser Permanente: Go online to www.kp.org or call Customer
WELLNESS
Service at 1-800-813-2000.
How to Set Up Mail Order Prescriptions Group Health Options: After setting up an online account you can order refills online and have them mailed – free of charge – directly to you. Kaiser Permanente: After setting up an online account you can order refills online and have them mailed – free of charge – directly to you. 2011-2012 BENEFITS BOOK
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HEALTH BENEFITS QUICK START Check Your Eligibility for Health Benefits •
You must work at least 86* hours per month for three consecutive months to be eligible for these benefits. You do not need to wait until you are eligible to enroll, you can complete the form after you’re hired.
Enroll Individual Providers: You can enroll by logging in to www.myseiubenefits.org and filling out the enrollment form. Agency Providers: Talk with your employer about enrollment.
URGENT CARE
Look for Your ID Card After you enroll and are eligible you should receive an ID card in the mail. You will need the ID card number to access your benefits. If you do not receive the card by the 10th of the month that your coverage starts, call the MRC at 1-866-371-3200 if you are an Individual Provider or if you are an Agency Provider, talk with your employer. Look for and write down your nearest Urgent Care Center and keep it with your card for reference.
Fill Out Your Health Profile or Health Assessment The Health Profile or Assessment is an online quiz and report to help you manage your health. To help encourage participation, you will receive a check for $25 for filling it out.
Make a Primary Care Appointment
URGENT CARE
Use the online provider directory at www.ghc.org or www.kp.org to find a primary care doctor who’s a good match for you. You will receive $10 for attending a primary care appointment within the first three months of your coverage. URGENT CARE
Locate Your Nearest Urgent Care Center As soon as possible, you should identify the closest urgent care center to you in case of an emergency. You can find urgent care centers online at www.ghc.org or www.kp.org.
Manage Your Prescriptions If you have existing prescriptions, have them transferred to Group Health Options or Kaiser Permanente. Next, set up mail order prescription refills online to save money and save time. *The work requirement in each Home Care Aide’s governing Collective Bargaining Agreement (CBA) URGENT CARE determines their eligibility for the Trust’s benefits. Agency Providers should check the CBA for their agency to see if it has a different work requirement than 86 hours.
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WELLNESS
URGENT CARE
FREQUENTLY ASKED QUESTIONS COVERAGE BASICS 1. When I am outside Washington state or the United States am I covered by the plan? Yes, but you must contact the health insurance provider for specific benefits and claim submission procedures at: Group Health 1-888-901-4636 Kaiser 1-800-813-2000 Premera Blue Cross 1-800-722-1471 Willamette (contact the clinic where the services were provided) 2. Can I add dependents to my plan? Individual Provider: Dependents are not covered. The Individual Provider benefits do not allow coverage for dependents under this plan. Agency Provider: If you are covered by the Health Benefits Trust, you can cover dependents by paying the full premium for them through payroll deduction. Dependents can only be added when they are initially eligible or during the annual open enrollment period. Check with your employer for information. 3. How do I cancel my coverage and the corresponding paycheck deductions? The request must be made in writing and sent to the Health Benefits Trust via fax or U.S. Mail. Fax to 206-859-2637 or mail to SEIU Healthcare NW Health Benefits Trust PO Box 6, Mukilteo, WA 98275. Requests in writing before the 15th of the month will stop further payroll deductions. 4. If I haven’t received an ID card, who do I call? Allow up to 10 days after your coverage begins for processing and mailing your ID cards. After you enroll and are eligible you should receive an ID card in the mail. You will need the ID card number to access your benefits. If you do not receive the card by the 10th of the month that your coverage starts, call the MRC at 1-866-371-3200 if you are an Individual Provider or if you are an Agency Provider, talk with your employer. Look for and write down your nearest Urgent Care Center and keep it with your card for reference. 5. Is dental or vision coverage included with this plan? Yes. Vision coverage is part of your medical plan administered by your medical health insurance provider – Group Health or Kaiser. You have the choice of dental coverage either through Premera Blue Cross or Willamette. 6. Is there a pre-existing condition waiting period? Yes. It is a 3-month waiting period unless you have had prior documented creditable group coverage which can be used as a credit toward the waiting period.
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FREQUENTLY ASKED QUESTIONS ELIGIBILITY 7. Can I use authorized, unclaimed hours from a previous month to satisfy my hour requirement in a subsequent month? No. For the purpose of health care insurance eligibility, hours are only applicable to the month in which they are authorized, not when they are claimed or paid. 8. How do I enroll for coverage? Individual Provider: Log on to www.myseiubenefits.org to complete enrollment or call the Member Resource Center at 1-866-3713200.
How do I enroll for coverage? Individual Provider: Log on to www.myseiubenefits.org to complete enrollment or call the Member Resource Center at 1-866-371-3200. Agency Provider: Contact your employer to coordinate your enrollment.
Agency Provider: Contact your employer to coordinate your enrollment. 9. How many hours do I have to work for continuing coverage? After your coverage begins, you must work at least 86 hours each month to have continuous coverage. The work requirement in each Home Care Aide’s governing Collective Bargaining Agreement (CBA) determines their eligibility for the Trust’s benefits. Agency Providers should check the CBA for their agency to see if it has a different work requirement than 86 hours. 10. I don’t have enough hours some months resulting in a lapse in coverage, do I have to meet the initial eligibility requirements again? If you are not covered by the plan for 12 months you need to re-qualify. 11. I work for a Home Care Agency and I’m also an Individual Provider. If I’m currently enrolled in my agency employer’s plan, can I terminate that coverage and enroll in the Health Benefits Trust as an Individual Provider instead of keeping my agency plan? Yes, but please keep in mind the initial eligibility requirements when determining your cancellation date. You’ll need to keep your current plan until your coverage as an Individual Provider begins. NOTE: You cannot be covered under both the Health Benefits Trust as an Individual Provider and another employer’s plan.
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FREQUENTLY ASKED QUESTIONS 12. What happens if I work less than 86 hours in a month after I am enrolled in the plan? You will NOT have coverage the second month following the month you worked less than 86 hours. Example: If you work only 50 hours in September, no deduction will be taken from your October paycheck and you will not have coverage for the month of November. However, if you do not work enough hours in a month, you may choose to pay the full monthly (COBRA) premium yourself. The Health Benefits Trust will send you a COBRA notice and election form and if you sign-up for COBRA benefits, you will receive a bill for payment. 13. When can I submit my enrollment form for coverage? Individual Provider: You should enroll as soon as you have authorization to work as an Individual Provider. Agency Provider: Contact your employer to coordinate your enrollment.
MISCELLANEOUS 14. I am an Individual Provider. What if I report my hours to Social Service Payment System (SSPS) so late that they don’t make the $25 deduction from my check? You will need to notify the Health Benefits Trust and mail in a check or money order for $25 payable to SEIU Healthcare NW Benefits Trust, PO Box 6, Mukilteo, WA 98275. You will also need to send a copy of your paycheck stub (aka Remittance Advice) and invoice showing you claimed at least 86 hours for that month. It is very important to report your hours to SSPS in a timely manner to avoid having to make a payment by mail. Your health insurance provider may not be able to verify your eligibility and your coverage will be considered lapsed until we receive your check and supporting documentation. 15. Can I be covered by another plan at the same time that I’m enrolled in the Health Benefits Trust Plan and use it as secondary coverage? As in Individual Provider or Agency Provider, participants may not have other coverage. This includes Basic Health Plan, another employer’s coverage or another family member’s coverage. The only exception is that you may retain Medicare or Medicaid coverage while enrolled in the Health Benefits Trust Plan. 16. How do I notify you that my address has changed? A request for an address change must be made to either your DSHS case worker or to Social Service Payment System (SSPS) directly if you are an Individual Provider. If you are an Agency Provider, contact your employer to make this change. 54
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Is dental or coverage in with this pl
r vision ncluded lan?
FREQUENTLY ASKED QUESTIONS 17. I currently have coverage, but not through the Health Benefits Trust plan. Can I enroll in the Health Benefits Trust plan if my other current coverage terminates? Yes. 18. I want to change my dental insurance provider, how can I do this?
Is dental or vision coverage included with this plan? Yes. Vision coverage is part of your medical plan administered by your medical insurance provider – Group Health or Kaiser. You have the choice of dental coverage either through Premera Blue Cross or Willamette.
Typically, this is only allowed during the annual open enrollment period that takes place in July of each year and has an August 1 effective date. If you are an Agency Provider, please contact your employer about open enrollment or other location change options available. If you are an Individual Provider, please call the Member Resource Center toll-free at 1-866-371-3200 about options for changing dental insurance providers. 19. If I cancel my insurance, can I enroll again later?
Yes, but if you have voluntarily cancelled your coverage, you will have to meet the initial eligibility requirements again in order to regain coverage. If you are an Agency provider, you cannot enroll again until the next annual open enrollment. 20. If I have coverage through my spouse, can I cancel that coverage and sign up for the Health Benefits Trust plan? Yes, but please keep in mind the initial eligibility requirements when determining your cancellation date. 21. What benefit plans are offered by the Health Benefits Trust? Currently, three insurance providers provide fully insured medical and/or dental coverage and one insurance provider provides self-insured dental coverage. Providers currently include: Group Health Options, Kaiser Permanente, Premera Blue Cross Self-insured Dental, and Willamette Dental Group. Trust enrollees are automatically enrolled in the Group Health coverage unless they reside in the Kaiser Permanente service area (southwest Washington and Portland, OR areas). Trust enrollees have a choice of dental insurance providers. 22. What if I am currently on COBRA through another plan? Can I cancel COBRA and enroll?
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POLICIES
Yes. There is a place on the enrollment application to indicate the current plan termination date.
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FREQUENTLY ASKED QUESTIONS 23. What if I have Washington’s Basic Health Plan (BHP) coverage? Can I enroll in this plan? Only if you cancel your BHP coverage. You cannot have both. There is a place on the Health Benefit Trust’s enrollment application to indicate the termination date of the current coverage. 24. When will my coverage be effective? Individual Providers: Log on to www.myseiubenefits.org and use the eligibility calculator to estimate when your coverage will begin or call the Member Resource Center at 1-866-371-3200. Agency Providers: please contact your Human Resources department to coordinate your enrollment. 25. Why do you need prior coverage information? HIPAA Law allows prior group coverage to be used as a credit toward the required pre-existing condition waiting period.
Who do I contact if I have questions about my benefits? Contact your insurance provider directly for an explanation of benefits and/or questions you have about claims. Group Health Options 1-888-901-4636 www.ghc.org Kaiser Permanente 1-800-813-2000 www.kp.org Premera Blue Cross (Dental) 1-800-722-1471 www.premera.com Willamette Dental 1-800-359-6019 www.willamettedental.com
Who do I call to enroll or ask eligibility questions? Contact the Member Resource Center toll-free at 1-866-371-3200.
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FREQUENTLY ASKED QUESTIONS Group Health Options Specific Questions 26. What if I don’t want to see any doctors who practice with Group Health Medical Centers? Each time you seek health care services, you can choose to use your in-network providers, or not. Your highest level of benefits ($0 deductible) will be found using in-network providers: Group Health Physicians for the POS (Options) plan and First Choice Health Network / Beech Street Network of Providers for the PPO (Options PPO) plan. You will pay more out of pocket costs by using an out-of-network provider. For example, you will have a $500 deductible. 27. What does Group Health Options POS vs. PPO mean? If you live within 30 miles of a Group Health facility or contracted provider, you will automatically be enrolled in the POS plan. If you live beyond 30 miles, you will automatically be enrolled in the PPO plan. In both plans, you have the choice of in-network or out-of-network providers each time you seek service. 28. How do I look for a provider available to me through Group Health Options? For POS Plan (within 30 miles of Group Health facilities): On left hand column of www.ghc.org, click on “Doctors & Healthcare Services”; then click on “Provider Directory”; then click on “Select a health plan provider network” and choose “Options.” For PPO Plan (all others): On left hand column of GHC website, click on “Doctors & Healthcare Services”; then click on “Provider Directory”; then click on “Select a health plan provider network” and choose “Options PPO.” Or call Group Health Customer Service toll free: 1-888-901-4636 •
Finding a provider
•
Specific benefit questions
•
Complex medical care case management
•
Inpatient care case management
POLICIES
29. How do I look up my Group Health Medical Centers providers? On the left hand side of the www.ghc.org website, click “Pharmacy Services.” 2011-2012 BENEFITS BOOK
57
FREQUENTLY ASKED QUESTIONS Group Health Options PLANS Group Health Options Point of Service POS Plan (POS)
Group Health Options, PPO Plan You will be automatically enrolled in this plan
You will be automatically enrolled in this
if you live farther than 30 miles from a Group
plan if you live within 30 miles of a Group
Health Medical Center facility or contracted
Health Medical Center facility or con-
provider.
tracted provider. You can choose to access coverage in- or
The First Choice Health Network has an
out-of-network each time you seek service.
extensive panel of preferred providers in WA,
You do not have to see the physicians who
OR, ID, AK and MT. Beech Street providers
practice at Group Health Medical Centers
are located in all other states.
locations, although use of these providers will give you the most cost savings.
“Options”
“Options PPO” Network
Options is the POS plans giving you in-
In-network care is provided by First Choice
network access to Group Health Medical
Health Network and Beech Street providers.
Centers care, and care from contracted
Out-of-network care is provided by any other
providers. Out-of-network care is provided
licensed provider.
by First Choice Health Network Providers.
Link to look up both Options and Options PPO Providers. http://myseiu.be/imSCSp
Pharmacy www.ghc.org/pharmacy/index.jhtml POS Plan
PPO Plan
In-network: Any Group Health Medi-
In-network: Group Health Medical Centers and
cal Centers or contracted community
MedImpact pharmacies.
pharmacy.;
Out-of-network: All other pharmacies
Out-of-network: Med Impact Pharmacies
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MYSEIUBENEFITS.ORG
FREQUENTLY ASKED QUESTIONS Kaiser Permanente Specific Questions 30. What is Kaiser Permanente’s Service area? If you live in any of the following counties/zip codes, your medical coverage will be provided by Kaiser Permanente’s HMO plan. Washington counties: Clark, Cowlitz, Lewis 98591 98593 98596, Skamania 98639 98648, Wahkiakum 98612 98647 Oregon counties: Multnomah, Polk, Washington, Yamhill 31. Do I have out-of-network coverage under Kaiser Permanente? No (with the exception of emergency services). To access your comprehensive coverage, you must use a Kaiser Permanente provider/facility. www.kp.org Link to find Kaiser Permanente Providers http://myseiu.be/mTdBBa 32. Kaiser Permanente Membership Services Or call Kaiser Permanente Membership Services toll free: 1-800-813-2000 • • • • • •
Choose a primary care provider Specific benefit questions Complex medical care case management Inpatient care case management Speak to an advice nurse Ask about Kaiser Permanente facilities across the country
33. Register for Kaiser Online Access
2011-2012 BENEFITS BOOK
POLICIES
• E-mail your doctor’s office • View select test results • Order prescription refills (and have them mailed to you, with free shipping) • Request or cancel routine appointments • Review recent past office visits • See a list of your recent immunizations and allergies • Act for a family member (e-mail your child’s doctor, and more) • Receive our monthly e-newsletter Register at https://members.kaiserpermanente.org/redirects/register/
59
BENEFIT SUMMARIES The following pages are benefit summaries, only, and are not intended to replace the specifics of the individual plan’s Certificate of Coverage, Contract, or Evidence of Insurance. If there is a contradiction, the Certificate of Coverage, Contract, or Evidence of Insurance will take precedence.
IF YOU HAVE QUESTIONS If you have questions about your plan’s coverage, contact your health insurance provider. Group Health Options www.ghc.org 1-888-901-4636 Mon.-Fri., 8 a.m.-5 p.m. Kaiser Permanente 1-800-813-2000 www.kp.org Premera Blue Cross (Dental) 1-800-722-1471 www.premera.com Willamette Dental 1-800-359-6019 www.willamettedental.com
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MYSEIUBENEFITS.ORG
GROUP HEALTH OPTIONS - Benefit Summaries Questions? 1-888-901-4636 www.ghc.org NOTE: This is a benefit summary, only, and is not intended to replace the specifics of the plan’s Certificate of Coverage, Contract, or Evidence of Insurance. If there is a contradiction, the Certificate of Coverage, Contract, or Evidence of Insurance will take precedence.
2011-2012 BENEFITS BOOK
61
Options PPO Preferred Provider Network (PPN)
BENEFIT
Non-Preferred Provider Network
Plan deductible
No annual deductible
Individual deductible: $500 per calendar year
Individual deductible carryover
Not applicable
4th quarter carryover applies
No plan coinsurance
Plan pays 80%, you pay 20% of the Usual, Customary and Reasonable (UCR) charges.
Individual out-of-pocket limit: $1,000
Individual out-of-pocket limit: $2,000 per calendar year
Out-of-pocket expenses for the following covered services are included in the out-of-pocket limit: Inpatient services, outpatient services, emergency services at a Preferred Provider Network (PPN) facility and ambulance services.
Out-of-pocket expenses for the following covered services are included in the out-of-pocket limit:
Pre-existing condition (PEC) waiting period
No PEC
Same as preferred provider network
Lifetime maximum
Unlimited
Shared with preferred provider maximum
Outpatient services (Office visits)
$10 copay
$10 copay, deductible and coinsurance apply
Inpatient services: $100 copay, per day for up to 5 days per admit
Inpatient services: $100 copay, per day for up to 5 days per admit Deductible and coinsurance apply
Outpatient surgery: $50 copay
Outpatient surgery: $50 copay, deductible and coinsurance apply
Prescription drugs (some injectable drugs may be covered under Outpatient services)
Formulary generic/formulary brand $15/$30 copay per 30 day supply
Formulary generic/formulary brand $20/$35 copay per 30 day supply
Prescription mail order
$5 discount per 30 day supply
Not covered
12 visits per calendar year
Shared with preferred provider visit limit $10 copay, deductible and coinsurance apply
Plan coinsurance
Out-of-pocket limit
Hospital services
Acupuncture Ambulance services
$10 copay
Plan coinsurance and emergency services at a Preferred Provider Network (PPN) facility.
Plan pays 80%, you pay 20%
Same as preferred provider benefit
Inpatient: $100 copay, per day for up to 5 days per admit
Inpatient: $100 copay, per day for up to 5 days per admit Deductible and coinsurance apply
Outpatient: $10 copay
Outpatient: $10 copay, deductible and coinsurance apply
Chemical dependency
This is a brief summary of benefits. THIS IS NOT A CONTRACT OR CERTIFICATE OF COVERAGE. All benefit descriptions, including alternative care, are for medically necessary services. The Member will be charged the lesser of the cost share for the covered service or the actual charge for that service. For full coverage provisions, including limitations, please refer to your certificate of coverage. In accordance with the Patient Protection and Affordable Care Act of 2010, •The lifetime maximum on the dollar value of covered essential health benefits no longer applies. Members whose coverage ended by reason of reaching a lifetime limit under this plan are eligible to enroll in this plan. Effective date 8/1/11.
Form No. 015-WA (4/08) Contract No. 001-WA (4/06)
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MYSEIUBENEFITS.ORG
Options PPO BENEFIT Devices, equipment and supplies • Durable medical equipment • Orthopedic appliances • Post-mastectomy bras limited to two (2) every six (6) months
Preferred Provider Network (PPN)
Non-Preferred Provider Network
Covered at 50%
Covered at 50%, deductible applies
Covered at 50%
Covered at 50%, deductible applies
Diabetic supplies
Insulin, needles, syringes and lancets-see Prescription drugs. External insulin pumps, blood glucose monitors, testing reagents and supplies-see Devices, equipment and supplies. When Devices, equipment and supplies or Prescription drugs are covered and have benefit limits, diabetic supplies are not subject to these limits.
Insulin, needles, syringes and lancets-see Prescription drugs. External insulin pumps, blood glucose monitors, testing reagents and supplies-see Devices, equipment and supplies. When Devices, equipment and supplies or Prescription drugs are covered and have benefit limits, diabetic supplies are not subject to these limits.
Diagnostic lab and X-ray services
Inpatient: Covered under Hospital services Outpatient: Covered in full
Inpatient: Covered under Hospital services Outpatient: Deductible and coinsurance apply
Emergency services (copay waived if admitted)
$200 copay
$200 copay
Hearing exams (routine)
$10 copay
$10 copay, deductible and coinsurance apply
Hearing hardware
Not covered
Not covered
Home health services
Covered in full up to 130 visits total per calendar year
Shared with preferred provider visit limit Deductible and coinsurance apply
Hospice services
Covered in full
Deductible and coinsurance apply
Infertility services
Not covered
Not covered
Manipulative therapy
12 visits per calendar year $10 copay
Shared with preferred provider visit limit $10 copay, deductible and coinsurance apply
12 visits per calendar year
Shared with preferred provider visit limit $10 copay, deductible and coinsurance apply
• Ostomy supplies • Prosthetic devices
Massage services
Maternity services
$10 copay Inpatient: $100 copay, per day for up to 5 days per admit Outpatient: $10 copay
Mental Health
Inpatient: $100 copay, per day for up to 5 days per admit Deductible and coinsurance apply Outpatient: $10 copay, deductible and coinsurance apply
Inpatient: $100 copay, per day for up to 5 days per admit
Inpatient: $100 copay, per day for up to 5 days per admit Deductible and coinsurance apply Outpatient: $10 copay Outpatient: $10 copay, deductible and coinsurance apply Form No. 015-WA (4/08) Contract No. 001-WA (4/06)
2011-2012 BENEFITS BOOK
63
Options PPO BENEFIT
Naturopathy
Preferred Provider Network (PPN) 12 visits per calendar year $10 copay
Non-Preferred Provider Network Shared with preferred provider visit limit $10 copay, deductible and coinsurance apply
Newborn Services
Any applicable coinsurance applies to the newborn while both mother and baby are confined. Otherwise, all applicable inpatient cost shares apply. Office visits: See Outpatient Services; Routine well care: See Preventive care.
Any applicable coinsurance applies to the newborn while both mother and baby are confined. Otherwise, all applicable inpatient cost shares apply. Office visits: See Outpatient Services; Routine well care: See Preventive care.
Obesity-related surgery (bariatric)
Not covered
Not covered
Unlimited, no waiting period
Not covered
Organ transplants Donor search & harvest applies to lifetime max
Inpatient: $100 copay, per day for up to 5 days per admit Outpatient: $10 copay
Preventive care Well-care physicals, immunizations, Pap smear exams, mammograms
Covered in full
Rehabilitation services (Occupational, speech, physical including services for neurodevelopmentally disabled children age six and under) Rehabilitation visits are a total of combined therapy visits per calendar year
Inpatient: 60 days per calendar year $100 copay, per day for up to 5 days per admit
Skilled nursing facility
Sterilization (vasectomy, tubal ligation)*
Temporomandibular Joint (TMJ) services
Not covered Routine mammograms: Deductible and coinsurance apply
Outpatient: 60 visits per calendar year $10 copay
Inpatient: Day limits shared with preferred provider benefit limit $100 copay, per day for up to 5 days per admit Deductible and coinsurance apply Outpatient: Visit limits shared with preferred provider benefit limit $10 copay, deductible and coinsurance apply
Covered in full up to 60 days per calendar year
Day limits shared with preferred provider benefit, deductible and coinsurance apply
Inpatient: $100 copay, per day for up to 5 days per admit
Inpatient: $100 copay, per day for up to 5 days per admit Deductible and coinsurance apply Outpatient: $10 copay, deductible and coinsurance apply
Outpatient: $10 copay $1,000 per calendar year; $5,000 lifetime max
Shared with preferred provider benefit
Inpatient: $100 copay, per day for up to 5 days per admit
Inpatient: $100 copay, per day for up to 5 days per admit Deductible and coinsurance apply Outpatient: $10 copay, deductible and coinsurance apply
Outpatient: $10 copay Tobacco cessation counseling
Free & Clear Program - covered Applicable cost shares apply in full
Routine vision care (1 visit every 12 months) Optical hardware Lenses, including contact lenses and frames
$10 copay
$10 copay, deductible and coinsurance apply
$200Â per 24 months
Shared with preferred provider benefit
Coverage provided by Group Health Options * Not available for Catholic Community Services Home Care Aides
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MYSEIUBENEFITS.ORG
RQ-45343
Options BENEFIT Plan deductible Individual deductible carryover
Inside Network No annual deductible
Outside Network Individual deductible: $500 per calendar year
Not applicable
4th quarter carryover applies
No plan coinsurance
Plan pays 80%, you pay 20% of the Usual, Customary and Reasonable (UCR) charges.
Individual out-of-pocket limit: $1,000
Individual out-of-pocket limit: $2,000
Plan coinsurance
Out-of-pocket expenses for the Out-of-pocket expenses for the following covered services are following covered services are included in the out-of-pocket limit: included in the out-of-pocket limit: Out-of-pocket limit
Inpatient services, outpatient services, emergency services at a Managed Health Care Network (MHCN) facility and ambulance services.
Plan coinsurance, emergency services at a non-Managed Health Care Network (MHCN) facility.
Pre-existing condition (PEC) waiting period
No PEC
Same as in-network
Lifetime maximum
Unlimited
Shared with in-network maximum
Outpatient services (Office visits)
$10 copay
$10 copay, deductible and coinsurance apply
Hospital services
Inpatient services: $100 copay, per Inpatient services: $100 copay, day for up to 5 days per admit per day for up to 5 days per admit Deductible and coinsurance apply Outpatient surgery: $50 copay Outpatient surgery: $50 copay, deductible and coinsurance apply
Prescription drugs (some injectable drugs may be covered under Outpatient services)
Formulary generic/formulary brand Formulary generic/formulary $15/$30 copay per 30 day supply brand $20/$35 copay per 30 day supply
Prescription mail order
$5 discount per 30 day supply
Acupuncture
Self-referred up to 8 visits per medical diagnosis per calendar year; additional visits when approved by the plan $10 copay
Ambulance services
Plan pays 80%, you pay 20%
Chemical dependency
Inpatient: $100 copay, per day for Inpatient: $100 copay, per day for up to 5 days per admit up to 5 days per admit Deductible and coinsurance apply Outpatient: $10 copay Outpatient: $10 copay, deductible and coinsurance apply
Not covered $10 copay, deductible and coinsurance apply
Same as in-network
This is a brief summary of benefits. THIS IS NOT A CONTRACT OR CERTIFICATE OF COVERAGE. All benefit descriptions, including alternative care, are for medically necessary services. The Member will be charged the lesser of the cost share for the covered service or the actual charge for that service. For full coverage provisions, including limitations, please refer to your certificate of coverage. In accordance with the Patient Protection and Affordable Care Act of 2010, • The lifetime maximum on the dollar value of covered essential health benefits no longer applies. Members whose coverage ended by reason of reaching a lifetime limit under this plan are eligible to enroll in this plan. Effective date 8/1/11.
2011-2012 BENEFITS BOOK
65
Options BENEFIT Devices, equipment and supplies • Durable medical equipment • Orthopedic appliances • Post-mastectomy bras limited to two (2) every six (6) months
Inside Network
Outside Network
Covered at 50%
Covered at 50%, deductible applies
Covered at 50%
Covered at 50%, deductible applies
Insulin, needles, syringes and lancets-see Prescription drugs. External insulin pumps, blood glucose monitors, testing reagents and supplies-see Devices, equipment and supplies. When Devices, equipment and supplies or Prescription drugs are covered and have benefit limits, diabetic supplies are not subject to these limits.
Insulin, needles, syringes and lancets-see Prescription drugs. External insulin pumps, blood glucose monitors, testing reagents and supplies-see Devices, equipment and supplies. When Devices, equipment and supplies or Prescription drugs are covered and have benefit limits, diabetic supplies are not subject to these limits.
Inpatient: Covered under Hospital services Outpatient: MRI/PET/CT - $50 copay
Inpatient: Covered under Hospital services Outpatient: MRI/PET/CT - $50 copay
Diagnostic lab and X-ray services
High end radiology imaging services such as CT, MR and PET must be determined Medically Necessary and require preauthorization except when associated with Emergency care or inpatient services.
High end radiology imaging services such as CT, MR and PET must be determined Medically Necessary and require preauthorization except when associated with Emergency care or inpatient services.
Emergency services (copay waived if admitted)
$200 copay
$200 copay
$10 copay
$10 copay, deductible and coinsurance apply
Not covered
Not covered
Covered in full. No visit limit.
No visit limit. Deductible and coinsurance apply
Hospice services
Covered in full
Deductible and coinsurance apply
Infertility services
Not covered
Not covered
Manipulative therapy
Self-referred up to 10 visits per calendar year $10 copay
Visit limits shared with in-network $10 copay, deductible and coinsurance apply
Massage services
See Rehabilitation services
See Rehabilitation services
Maternity services
Inpatient: $100 copay, per day for Inpatient: $100 copay, per day up to 5 days per admit for up to 5 days per admit Deductible and coinsurance apply Outpatient: $10 copay Outpatient: $10 copay, deductible and coinsurance apply
Mental Health
Inpatient: $100 copay, per day for Inpatient: $100 copay, per day for up to 5 days per admit up to 5 days per admit Deductible and coinsurance apply Outpatient: $10 copay Outpatient: $10 copay, deductible and coinsurance apply
• Ostomy supplies • Prosthetic devices
Diabetic supplies
Hearing exams (routine) Hearing hardware Home health services
66
MYSEIUBENEFITS.ORG
Options BENEFIT
Naturopathy
Newborn Services
Obesity-related surgery (bariatric) Organ transplants Donor search & harvest applies to lifetime max
Preventive care Well-care physicals, immunizations, Pap smear exams, mammograms
Rehabilitation services (Occupational, speech, physical)) Rehabilitation visits are a total of combined therapy visits per calendar year
Skilled nursing facility
Inside Network Self-referred up to 3 visits per medical diagnosis per calendar year; additional visits when approved by plan $10 copay
Outside Network $10 copay, deductible and coinsurance apply
Any applicable coinsurance applies to the newborn while both mother and baby are confined. Otherwise, all applicable inpatient cost shares apply. Office visits: See Outpatient Services; Routine well care: See Preventive care.
Any applicable coinsurance applies to the newborn while both mother and baby are confined. Otherwise, all applicable inpatient cost shares apply. Office visits: See Outpatient Services; Routine well care: See Preventive care.
Not covered
Not covered
Unlimited, no waiting period Shared with in-network Inpatient: $100 copay, per day for Inpatient: $100 copay, per day for up to 5 days per admit up to 5 days per admit Deductible and coinsurance apply Outpatient: $10 copay Outpatient: $10 copay, deductible and coinsurance apply Covered in full
$300 per person, coinsurance applies Routine mammograms: Deductible and coinsurance apply
Inpatient: 60 days per calendar year $100 copay, per day for up to 5 days per admit Outpatient:60 visits per calendar year $10 copay Covered in full up to 60 days per calendar year
Inpatient: Day limits shared with in-network $100 copay, per day for up to 5 days per admit Deductible and coinsurance apply Outpatient: Visit limits shared with in-network $10 copay, deductible and coinsurance apply Day limits shared with in-network benefit, deductible and coinsurance apply
Sterilization (vasectomy, tubal ligation)*
Inpatient: $100 copay, per day for Inpatient: $100 copay, per day for up to 5 days per admit up to 5 days per admit Deductible and coinsurance apply Outpatient: $10 copay Outpatient: $10 copay, deductible and coinsurance apply
Temporomandibular Joint (TMJ) services
$1,000 per calendar year; $5,000 Shared with in-network lifetime max Inpatient: $100 copay, per day for Inpatient: $100 copay, per day for up to 5 days per admit up to 5 days per admit Deductible and coinsurance apply Outpatient: $10 copay Outpatient: $10 copay, deductible and coinsurance apply
Tobacco cessation Free & Clear Program - covered in full counseling $10 copay Routine vision care (1 visit every 12 months) Optical hardware $200Â per 24 months Lenses, including contact lenses and frames Coverage provided by Group Health Options
* Not available for Catholic Community Services Home Care Aides
Applicable cost shares apply $10 copay, deductible and coinsurance apply Shared with in-network
RQ-45343
2011-2012 BENEFITS BOOK
67
KAISER PERMANENTE HEALTH Benefit Summaries Questions? 1-800-813-2000 or (503) 813-2000 Member Services Weekday Hours 8am-6pm Member Services Weekend Hours Closed www.kp.org NOTE: This is a benefit summary, only, and is not intended to replace the specifics of the plan’s Certificate of Coverage, Contract, or Evidence of Insurance. If there is a contradiction, the Certificate of Coverage, Contract, or Evidence of Insurance will take precedence.
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MYSEIUBENEFITS.ORG
Individual Providers Medical Plan B
General Information www.kp.org
Website Member Services Number
1-800-813-2000 or (503) 813-2000
Member Services Weekday Hours
8am-6pm
Member Services Weekend Hours
Closed
Annual Deductible: Individual
None
Annual Out-of-Pocket Max: Individual
$750 Individual Office Visits (Outpatient)
Primary Care
$10 copay
Specialty Care
$10 copay / $0 preventative
Preventive Care
100% covered
Scheduled Prenatal Visits and 1st Postpartum Visit
100% covered
Well-Baby Care (23 months or younger)
100% covered
Vision Exam - Optometrist
$10 copay
Vision Exam - Ophthalmologist
$10 copay
Physical, Occupational, Speech Therapy Outpatient/Ambulatory Surgery
$10 copay $50 copay / $0 preventative
Continued on next page
This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, cost sharing, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and cost sharing. For a complete explanation, please refer to the applicable EOC, or to the Disclosure Form for California, or to the Member Handbook for Hawaii.
2011-2012 BENEFITS BOOK
69
Individual Providers Medical Plan B Cont’d.
Lab and X-Ray Laboratory
100% covered
X-Ray
100% covered
MRI/CT/PET/Nuclear Medicine
$50 copay Emergency Care
Ambulance (Ground or Air)
$75 copay
Emergency Room
$200 copay
Urgent Care
$30 copay Hospital Care (Inpatient)
Inpatient
$100 copay
Delivery and Inpatient Baby Care
$100 copay
Mental Health and Chemical Dependency Mental Health Outpatient (Individual)
$10 copay
Mental Health Outpatient (Group)
$10 copay
Mental Health Inpatient
$100 copay
Chemical Dependency Outpatient (Individual)
$10 copay
Chemical Dependency Outpatient (Group)
$10 copay
Chemical Dependency Inpatient
$100 copay Prescription Drugs
Pharmacy/Retail: Generic
$15 copay
Pharmacy/Retail: Brand
$30 copay
Pharmacy/Retail: Day Supply
30
Mail Order - Generic
$30 copay
Mail Order - Brand
$60 copay
Mail Order - Day Supply
90 Other
Skilled Nursing Facility (SNF) Infertility Services Hospice Care Home Health Care Durable Medical Equipment (DME)
100% covered; limited to 100 days per calendar year Diagnosis and treatment 50% covered 100% covered for patient diagnosed with life expectancy of 6 months or less 100% covered, limited to 130 days per year 20% coinsurance
Vision Hardware
$200 allowance, every 24 months
Vision Hardware
$10 copay for chiro, naturopathic, & acupuncture
This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, cost sharing, outof-pocket maximums, exclusions, or limitations, nor does it list all benefits and cost sharing. For a complete explanation, please refer to the applicable EOC, or to the Disclosure Form for California, or to the Member Handbook for Hawaii.
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MYSEIUBENEFITS.ORG
Agency Providers Medical Plan B
General Information Website
www.kp.org
Member Services Number
1-800-813-2000 or (503) 813-2000
Member Services Weekday Hours
8am-6pm
Member Services Weekend Hours
Closed
Annual Deductible: Individual/Family
None
Annual Out-of-Pocket Max: Individual/Family
$750 Individual/$2250 Family Office Visits (Outpatient)
Primary Care
$10 copay
Specialty Care
$10 copay / $0 preventative
Preventive Care
100% covered
Scheduled Prenatal Visits and 1st Postpartum Visit
100% covered
Well-Baby Care (23 months or younger)
100% covered
Vision Exam - Optometrist
$10 copay
Vision Exam - Ophthalmologist
$10 copay
Physical, Occupational, Speech Therapy
$10 copay
Outpatient/Ambulatory Surgery
$50 copay / $0 preventative
Continued on next page
This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, cost sharing, outof-pocket maximums, exclusions, or limitations, nor does it list all benefits and cost sharing. For a complete explanation, please refer to the applicable EOC, or to the Disclosure Form for California, or to the Member Handbook for Hawaii.
2011-2012 BENEFITS BOOK
71
Agency Providers Medical Plan B Cont’d.
Lab and X-Ray Laboratory
100% covered
X-Ray
100% covered
MRI/CT/PET/Nuclear Medicine
$50 copay Emergency Care
Ambulance (Ground or Air)
$75 copay
Emergency Room
$200 copay
Urgent Care
$30 copay Hospital Care (Inpatient)
Inpatient
$100 copay
Delivery and Inpatient Baby Care
$100 copay
Mental Health and Chemical Dependency Mental Health Outpatient (Individual)
$10 copay
Mental Health Outpatient (Group)
$10 copay
Mental Health Inpatient
$100 copay
Chemical Dependency Outpatient (Individual)
$10 copay
Chemical Dependency Outpatient (Group)
$10 copay
Chemical Dependency Inpatient
$100 copay Prescription Drugs
Pharmacy/Retail: Generic
$15 copay
Pharmacy/Retail: Brand
$30 copay
Pharmacy/Retail: Day Supply
30
Mail Order - Generic
$30 copay
Mail Order - Brand
$60 copay
Mail Order - Day Supply
90 Other
Skilled Nursing Facility (SNF) Infertility Services Hospice Care Home Health Care Durable Medical Equipment (DME)
100% covered; limited to 100 days per calendar year Diagnosis and treatment 50% covered 100% covered for patient diagnosed with life expectancy of 6 months or less 100% covered, limited to 130 days per year 20% coinsurance
Vision Hardware
$200 allowance, every 24 months
Vision Hardware
$10 copay for chiro, naturopathic, & acupuncture
This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, cost sharing, outof-pocket maximums, exclusions, or limitations, nor does it list all benefits and cost sharing. For a complete explanation, please refer to the applicable EOC, or to the Disclosure Form for California, or to the Member Handbook for Hawaii.
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MYSEIUBENEFITS.ORG
PREMERA DENTAL - Benefit Summaries
NOTE: This is a benefit summary only and is not intended to replace the specifics of the Self-funded Dental Plan Document. If there is a contradiction, the Plan Document will govern.
This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, cost sharing, outof-pocket maximums, exclusions, or limitations, nor does it list all benefits and cost sharing. For a complete explanation, please refer to the applicable EOC, or to the Disclosure Form for California, or to the Member Handbook for Hawaii.
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PREMERA DENTAL - Benefit Summaries Standard PPO Group Number: 1034825 Effective date: 8/1/2011 DENTAL PLAN
COVERED SERVICES
DENTAL PREFERENCES FLEX PLUS— STANDARD PPO – INDIVIDUAL PROVIDER IN-NETWORK
OUT-OF-NETWORK
Individual/Family Deductible PCY
$0
$50 (waived for diagnostic/ preventive)
DIAGNOSTIC/PREVENTIVE
$0
20%
$0
40%
- cleanings (limited to 2 PCY) - fluoride treatments (limited to 2 applications PCY for members age 19 and under) - routine oral exams (limited to 2 PCY) - routine x-rays (complete series or panoramic x-ray once every 5 calendar years, but not both) - sealants (limited to permanent teeth for members age 18 and under) - space maintainers BASIC - emergency exams (unlimited) - non-routine exams (limited to 1 PCY) - emergency palliative treatment - endodontic (root canal) treatment (limited to once per tooth every 2 calendar years) - fillings - full mouth debridement (limited to once every 3 calendar years) - periodontal maintenance (limited to 2 visits per calendar year) - periodontal scaling (limited to once per quadrant every 2 calendar years) - periodontal surgery once in the same quadrant every 3 calendar years
An Independent Licensee of the Blue Cross Blue Shield Association
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Continued on next page
BASIC Continued
$0
40%
20%
60%
$1,000 PCY
Shared with In-Network Cost Share
- limited occlusal adjustments (limited to 1 PCY) - re-cementing of crowns, inlays, bridgework and dentures - re-line, re-base, and adjustments when performed six or more months after denture installation - simple and surgical extractions - general anesthesia (limited to covered dental procedures at a dental care providers office when dentally necessary) MAJOR - repair of crowns, inlays, bridgework and dentures - inlays, onlays and crowns (replacements limited to once per tooth every 7 calendar years) - dentures, partials and fixed bridges (replacements limited to once every 7 calendar years) - implant and implant related services once every 7-consecutive years - Stainless steel crowns on non-permanent molars are limited to once per tooth every 5 calendar years Annual Maximum
Any deductibles, copays, and coinsurance percentages shown are amounts for which you’re responsible.
In-network services aren’t subject to a calendar year deductible. The out-of-network calendar year deductible is waived for Diagnostic/Preventive Care services. PCY = Per calendar year. Balance billing may apply if a provider is not contracted with Premera Blue Cross. Members are responsible for amounts in excess of the allowable charge. This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force. This benefit highlight is not a contract. For full coverage provisions, including a description of waiting periods, limitations and exclusions please contact Customer Service.
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Out-of-Area Plan Group Number: 1034826 Any deductibles, copays, and coinsurance percentages shown are amounts for which you’re responsible. Effective date: 8/1/2011 DENTAL PLAN COVERED SERVICES
DENTAL PREFERENCES FLEX PLUS— OUT OF AREA PLAN IN-NETWORK
OUT-OF-NETWORK
Individual/Family Deductible PCY
$0
$50 (waived for diagnostic/ preventive)
DIAGNOSTIC/PREVENTIVE
$0
$0
$0
20%
- cleanings (limited to 2 PCY) - fluoride treatments (limited to 2 applications PCY for members age 19 and under) - routine oral exams (limited to 2 PCY) - routine x-rays (complete series or panoramic x-ray once every 5 calendar years, but not both) - sealants (limited to permanent teeth for members age 18 and under) - space maintainers BASIC - emergency exams (unlimited) - non-routine exams (limited to 1 PCY) - emergency palliative treatment - endodontic (root canal) treatment (limited to once per tooth every 2 calendar years) - fillings - full mouth debridement (limited to once every 3 calendar years) - periodontal maintenance (limited to 2 visits per calendar year) - periodontal scaling (limited to once per quadrant every 2 calendar years) - periodontal surgery once in the same quadrant every 3 calendar years
An Independent Licensee of the Blue Cross Blue Shield Association
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Continued on next page
BASIC Continued
$0
20%
20%
50%
$1,000 PCY
Shared with In-Network Cost Share
- limited occlusal adjustments (limited to 1 PCY) - re-cementing of crowns, inlays, bridgework and dentures - re-line, re-base, and adjustments when performed six or more months after denture installation - simple and surgical extractions - general anesthesia (limited to covered dental procedures at a dental care providers office when dentally necessary) MAJOR - repair of crowns, inlays, bridgework and dentures - inlays, onlays and crowns (replacements limited to once per tooth every 7 calendar years) - dentures, partials and fixed bridges (replacements limited to once every 7 calendar years) - implant and implant related services once every 7-consecutive years - Stainless steel crowns on non-permanent molars are limited to once per tooth every 2 calendar years - Stainless steel crowns on permanent molars are limited to once per tooth every 5 calendar years Annual Maximum
In-network services aren’t subject to a calendar year deductible. The out-of-network calendar year deductible is waived for Diagnostic/Preventive Care services. PCY = Per calendar year. Balance billing may apply if a provider is not contracted with Premera Blue Cross. Members are responsible for amounts in excess of the allowable charge. This is not a complete explanation of covered services, exclusions, limitations, reductions or the terms under which the program may be continued in force. This benefit highlight is not a contract. For full coverage provisions, including a description of waiting periods, limitations and exclusions please contact Customer Service.
An Independent Licensee of the Blue Cross Blue Shield Association
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WILLAMETTE DENTAL - Benefit Summaries Questions? 1-800-359-6019 www.willamettedental.com
NOTE: This is a benefit summary only and is not intended to replace the specifics of the Self-funded Dental Plan Document. If there is a contradiction, the Plan Document will govern.
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IP Plan & Agency Plan
BENEFIT
CO-PAYMENT
Annual Maximum
No Annual Maximum*
Deductible
No Deductible
General Office Visit
$15 per Visit DIAGNOSTIC AND PREVENTIVE SERVICES
Routine and Emergency Exams
Covered at 100%
All X-rays
Covered at 100%
Teeth Cleaning
Covered at 100%
Fluoride Treatment
Covered at 100%
Sealants
Covered at 100%
Head and Neck Cancer Screening
Covered at 100%
Oral Hygiene Instruction
Covered at 100%
Periodontal Charting
Covered at 100%
Periodontal Evaluation
Covered at 100% RESTORATIVE DENTISTRY
Fillings (Amalgam)
Covered at 100%
Stainless Steel Crown
Covered at 100%
Porcelain-Metal Crown
$250 PROSTHETICS
Complete Upper or Lower Denture
$400
Bridge (per Tooth)
$250 ENDODONTICS AND PERIODONTICS
Root Canal Therapy – Anterior
$85
Root Canal Therapy – Bicuspid
$105
Root Canal Therapy – Molar
$130
Osseous Surgery (per Quadrant)
$150
Root Planing (per Quadrant)
$75 ORAL SURGERY
Routine Extraction (Single Tooth)
Covered at 100%
Surgical Extraction
$100 ORTHODONTIA
Pre-Orthodontic Service Comprehensive Orthodontia
$150** Value Added Services Available MISCELLANEOUS
**Fee credited towards comprehensive orthodontic co-payment if patient accepts treatment plan.
Local Anesthesia (Novocain)
Covered at 100%
Dental Lab Fees
Covered at 100%
Nitrous Oxide
$40 per Visit
Specialty Office Visit
$30 per Visit
Emergency Office Visit
$50 per Visit
Out of Area Emergency Care Reimbursement up to $250 *TMJ has a $1000 annual maximum / $5000 lifetime maximum Form No. 015-WA (4/08) Contract No. 001-WA (4/06)
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QUESTIONS & APPEALS What if I Have a Health Insurance or Dental Coverage Question or an Appeal?
When you have questions or a complaint about health or dental coverage: Call the Customer Service Department of your insurer, or, for the Trust’s self-funded dental plan, Premera Blue Cross: Group Health Options 1-800-542-6312 www.ghc.org Kaiser Permanente 1-800-813-2000 www.kp.org Willamette Dental Oregon: 1-800-461-8994 Washington: 1-800-359-6019 www.willamettedental.com Self-funded Dental Plan Claims Administered by Premera Blue Cross 1-800-547-9515 www.premera.com
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QUESTIONS & APPEALS When you have an appeal: An appeal is a request to reconsider a decision to deny, modify, reduce, or end payment, coverage or authorization of coverage (known as an “adverse decision”). The appeal process for each of the Trust’s health and dental plans is different. You should review the Summary Plan Description of appeals procedures in your Benefits Summary provided by your insurer or, in the case of the Trust’s self-funded dental coverage, by Premera Blue Cross. The Summary Plan Description contains a full explanation of the appeals process. You may also call the Customer Service Department of your insurer or, in the case of the Trust’s self-funded dental coverage, Premera Blue Cross, for specific information about the appeals process. Those numbers are listed on the previous page. Your rights in an appeal: •
You must submit your appeals within 180 calendar days of the date you received notice of an “adverse decision.” Keep track of these deadlines as appeals that are filed late may not be considered.
•
You may request an expedited 72-hour review of your appeal when the adverse determination could jeopardize your life or health.
•
You may request all of the documents relevant to your request and the decision by the insurer or administrator.
•
You may submit additional comments, documents or other information to support your appeal.
More information about how to file an appeal can be found at “How to Appeal a Health Care Insurance Decision, A Guide for Consumers in Washington State” on the Office of the Insurance Commissioner’s website, www.insurance.wa.gov/consumers/health/Appeal/Table-of-Contents.shtml
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GLOSSARY AAA – Area Agency on Aging ABT – Accelerated Basic Training ADSA – Aging and Disability Services Administration Department of Department of Social and Health Services serving adults with chronic illnesses or conditions and people with developmental disabilities. AP – Agency Provider A Home Care Aide who works for an agency – agency provider ARC – Advocates for the Rights of Citizens with Developmental Disabilities BHP – Basic Health Plan of Washington CNA – Certified Nursing Assistant CE – Continuing Education Supplemental training required for skills development COBRA – A private-pay insurance that covers you if you have a lapse in coverage or you are between jobs cultural competency – An awareness of the customs, beliefs and religious practices of others DDD – Division of Developmental Disabilities diagnostic imaging – MRI (Magnetic Resonance Imaging), X-rays, mammograms DME – Durable Medical Equipment Walkers, crutches, etc. DSHS – Department of Social and Health Services HCS – Home Community Services The Home Community Services (HCS) Division of DSHS promotes, plans, develops and provides long-term care services for persons with disabilities and older adults who may need state funds (Medicaid) to help pay for them. health insurance provider – The company that manages your health insurance, for example Group Health, Kaiser Permanente. Health Risk Assessment or Health Profile – An online health assessment or questionnaire that assesses your general health and wellness through a series of questions
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GLOSSARY IP – Individual Provider A Home Care Aide that provides care to a consumer living in his or her home and whose employer of record is the Department of Social and Health Services. LPN – Licensed Practical Nurse MFOC – Modified Fundamentals of Caregiving MRC – Member Resource Center NDC – Nurse Delegated Core NDD – Nurse Delegation Diabetes orthopedic appliances – braces, splints, etc. PCP – Primary Care Provider The doctor you choose to oversee your care POS – Point of Service Insurance pays percentage of doctor visit that is out-of-network PPO – Preferred Provider Organization A provider who is in-network RN – Registered Nurse RNA – Registered Nurse’s Assistant S&O – Safety and Orientation TBI – Traumatic Brain Injury Training Wizard – A computer program that assists you in getting started at the Training Partnership www.myseiubenefits.org/wizard
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NOTICES About This Guide This handbook is intended to be an overview of your benefits and a general resource. For more detailed information about your health and dental benefits, you should consult the Summary Plan Description (SPD) and Certificate of Coverage for those benefits. This handbook is not a “Plan document” or the official SPD. In case of any conflict between this document and any “Plan document,” the terms of the Plan Document shall govern. The handbook is not a promise of benefits. All benefits described in the handbook are provided pursuant to existing collective bargaining agreements (CBA) and employer participation agreements with the SEIU Healthcare NW Health Benefits Trust and Training Partnership. Should the CBA or other agreements with the Health Benefits Trust and/or Training Partnership terminate, change or otherwise become ineffective, the benefits described in this book may also terminate or change.
Equal Opportunity The SEIU Healthcare NW Training Partnership (“Partnership”) admits students regardless of race, color, national origin, ethnic origin, gender, age, disability and sexual orientation to all the rights, privileges, programs, and activities generally accorded or made available to students by the Training Partnership. It does not discriminate on the basis of race, color, national origin, ethnic origin, gender, age, disability and sexual orientation in administration of its training and educational policies, admissions policies, scholarship and loan programs, and other Training Partnership administered programs.
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2011-2012 GUIDE TO TRAINING AND HEALTH BENEFITS Inside: • • •
Changes to Training Standards and Benefits Ways to stay healthy, save money and save time How to access training and health benefits online … and much more!
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