Arkansas State & Public School Employees

1. When can I enroll in the plan?
In 2011 PSE (Public School Employees) and ASE (Arkansas State Employees) open enrollment is in October for an effective date of January 1, 2012. ASE and PSE retirees will be moved to the retirement group upon their retirement date.

Open enrollment period: A time-period annually for employees to make changes to health-plan coverage.

2. Can my dependents be added to my plan after it is in effect?
Active employees may add eligible dependents during the group's open enrollment period or during a specific enrollment period based on a qualifying event. Please refer to your Summary Plan Description. Contact Employee Benefits Division if you have a family status change that meets the criteria for a special enrollment period.

Retirees cannot join the plan or add dependents after retirement unless there is an approved family status change. You must be on the plan at the time of retirement to be eligible to continue coverage.

3. What is the age limit for dependent coverage?
If your dependent is a child, they may join the Plan as long as they are your child, stepchild, or you have permanent legal guardianship for them and you can answer yes to one of the following questions:

Are they less than age twenty-six (26)?
Are they a qualified disabled dependent, and have they been medically certified as totally disabled due to mental or physical incapacity, and do you provide most, if not all, of their financial support?
Are they a Qualified Medical Child Support Order (QMCSO) dependent under age 26 and do you have a judgment, decree, or order issued under state law? For more eligibility information refer to the Summary Plan Description on www.arbenefits.org.

Proof of mental or physical incapacity: For dependent coverage to be provided due to mental or physical incapacity, proof of the child's dependency and incapacity must be submitted prior to the child's attainment of the applicable limiting age referenced in section above. Subsequent evaluation for continued incapacity and dependency may be required. Newly eligible employees may enroll an incapacitated dependent child provided the disability commenced before the limiting age, and the child has been continuously covered under a health benefit plan as a dependent of the employee since before attaining the limiting age.

4. When is my newborn covered?
The change form requesting coverage for your newborn must be submitted through Employee Benefits Division (EBD).

Coverage for an employee's newborn child shall become effective as of the date of birth, placement for adoption, or filing date of petition for adoption of the child if the employee gives notice of the child by submitting an application or change form for the child within 30 days of the child's date of birth. This deadline applies to members on all coverage tiers (employee only, employee + child(ren), employee + spouse, and employee + family).

5. What is a qualifying event for COBRA coverage?

Termination of an enrolled employee's employment (other than for gross misconduct) for any reason (layoff, resignation, retirement, etc.).
Reduction of work hours.
Death of the covered employee.
Divorce or legal separation from the covered employee.
Dependent child ceasing to meet eligibility requirements.
Retiree or retiree's spouse or child loses coverage within one year before or after the commencement of proceedings under Title 11.
When dependent loses coverage due to covered employee becoming entitled to Medicare.

6. What is a Certificate of Credible Coverage (COCC)?
A Certificate of Credible Coverage (COCC) lists your coverage with Health Advantage from the initial effective date to your termination date. This certificate is generated after your policy is terminated. Insurance companies use this certificate to reduce pre-existing time clauses and to verify insurance coverage with other carriers. Contact Employee Benefits Division if you need a COCC.

7. What services are subject to the deductible?

Bronze Plan
All covered services received from providers for medical, behavioral health and pharmacy services, except mandated childhood immunizations.

Health Plan Information

1. Do I need to take my member ID card each time I go to the doctor?
We strongly recommend that you carry your ID card with you at all times, and that your family members carry their ID cards with them as well. To ensure prompt payment of claims, please make sure that the information on your ID card is correct and that all providers have the correct date of birth and the spelling of your name.

2. What if I lose my ID card?
You may order cards online at www.arbenefits.org or by contacting the Employee Benefits Division (EBD) at 1-877-815-1017 or 501-682-9656 or Health Advantage Customer Service at 1-800-482-8416.

3. What is the difference between in-network and out-of-network services?
In-network services are covered services or supplies a member receives from plan physicians or plan providers. Out-of-network services are covered services or supplies a member receives from non-plan physicians or other non-plan providers that are not in the Health Advantage provider network chosen by your employer. Emergency care and urgent care services that are covered are paid at the in-network benefit level up to the allowable charge. The member may be billed the difference between billed charges and allowable charges for services received from non-plan providers.

4. Does Health Advantage provide online services for members?
Yes. You may access www.HealthAdvantage-hmo.com for the following:

Health plan information: General information about the health plan, referral information, preventive health information, BlueCard Program, and My Blueprint, which allows you to view claim information, is also available.
Provider Directory: A listing of all Network PCPs, Specialists, Hospitals, Pharmacies and other providers contracted by Health Advantage. Click on the directory specifically for your employer group.
Eligibility/claim information: By registering for My Blueprint, you may check membership eligibility and claims status, print a Personal Health Statement, and review primary care physician information.

5. What does my health plan cover and what will I need to pay?
Your health plan covers preventive and medical services as defined in your Summary Plan Description. You may be responsible for any applicable copayments, deductibles and/or coinsurance. Usually, you will be responsible for any applicable copayments and/or deductibles at the time of service and may receive a bill at a later date for your coinsurance responsibility. Depending on the type of benefit, prior approval may be required for certain specialty services.

6. What is a deductible?

Bronze Plan
The deductible is a flat dollar amount that you have to meet before Health Advantage starts paying on your claims. Any dollar amounts that you pay for your medical, pharmacy or behavioral health claims will apply to your deductible.

Gold Plan
The deductible is the amount of allowable charges for out-of-network covered services for which the member is responsible before the member pays the coinsurance and Health Advantage makes payment for a service received.

7. What services are subject to the deductible?

Bronze Plan
All covered services received from providers for medical, behavioral health and pharmacy services.

Gold Plan
All covered services received from non-plan providers except for emergency care and mandated childhood immunizations are subject to the out-of-network deductible. Copayments and coinsurance do not count toward the deductible.

8. What is a copayment?
A copayment is the predetermined fixed dollar amount a member must pay to receive a specific service. Copayment may mean a defined percentage of charges a member must pay to receive specific services. Copayments do not apply to the annual coinsurance maximum (out of pocket limit).

9. What is coinsurance?
Coinsurance is defined as a percentage of the allowable charge that a member pays for a service after any copayment is applied. Once the annual coinsurance maximum is met for each member or for the family, no further coinsurance will be charged for the current contract year.

10. What is applied to the annual coinsurance maximum?
The annual coinsurance maximum only applies to the coinsurance amounts for which the member is responsible. Coinsurance is a percentage (usually 20%) remaining after the ARBenefits Plan pays its portion. Copayments, any applicable deductible and non-covered amounts do not apply to the coinsurance maximum.

11. How can I make sure I receive covered services from in-plan physicians or plan providers?
When you are within the state of Arkansas, you may find a participating physician or provider by accessing the Health Advantage provider directory or contact Customer Service to verify whether a specific provider is in-network. Remember, click on the provider directory listed as Arkansas State Employees or Public School Personnel.

12. What can I do to reduce my out-of-pocket expenses?
Using participating providers and obtaining any required precertification prior to the service will reduce your out-of-pocket expenses.

13. Why would a health plan ask for additional information such as medical records?
Additional information may be requested when a claim is pended for review.

For example, to ensure the specific medical criteria are met. There are specific procedures that are only covered when specific criteria are met for coverage. The Health Advantage coverage policies are located on the Web site under the link "Coverage Policy".

14. What are my wellness benefits?
Your ARBenefits Plan provides some services recommended for the prevention and early detection of disease. Promotion of these services is accomplished through direct communication with your physician. The preventive health guidelines reflect recommendations from leading authorities and local practitioners and are meant to be a guide. Treatment is at the clinical discretion of your physician. You may also review the wellness benefit chart information in your Summary Plan Description at www.arbenefits.org.

Routine dental exams are not covered. If you are an active public school employee with group dental benefits through Arkansas Blue Cross and Blue Shield, please refer to benefit information from DentalBlue.

15. Which services need pre-certification?
The Arkansas Employee Benefits Division (EBD) has contracted with a third-party vendor, American Health Holding (AHH), not affiliated with Arkansas Blue Cross and Blue Shield or Health Advantage, effective Oct. 1, 2007, for the Arkansas State and Public School employees, to provide utilization management services that include pre-certification, pre-determination and concurrent review.Services that require pre-certification from AHH include but are not limited to are:

Inpatient rehabilitation	Cognitive rehab	Home infusion therapy
Residential treatment	Specific therapy	Home nursing visits
MRI/MRA	Skilled nursing facilities	Pet scan
Transplants
Limited out-patient hospital surgical procedures and specific surgeries

Please refer to your Summary Plan Description for specific information. It is your responsibility to ensure that your provider contacts AHH at 1-877-815-1017 for pre-certification for you to receive these types of services.

16. Do I need a referral to receive medical care from a plan specialist?
No. Members may receive covered services without a referral. For in-network benefits, members will need to stay in the Health Advantage network of participating hospitals and doctors.

17. If I am out of the Health Advantage service area and have an unexpected illness or injury, what should I do?
ARBenefits plans cover emergency care as in network regardless of the facility's participation status. If you are having an emergency please seek medical attention at the nearest facility. If you are in another state and need non-emergent medical care, and are concerned about a doctor or hospital's network status, be assured that Health Advantage covers you anywhere in the United States. Your doctor or hospital needs to be in the PPO network of their local state's provider network. You can access a list of out-of-state listings through the Blue National Doctor & Hospital Finder Web site.

18. What medical conditions are considered an emergency?
Conditions that are so severe as to cause serious disability if not treated are considered emergencies. Some examples of emergencies that require immediate attention include:

*Heart attack or severe chest pain	*Serious burns	*Acute abdominal pain
*Uncontrollable bleeding	*Poisoning	*High fever
*Broken bones	*Unconsciousness	*Severe shortness of breath
*Convulsions or choking

19. Are weight-loss programs covered?
Please contact EBD at 1-877-815-1017 and press option 1 and someone there will be able to assist you.

20. I am pregnant; what should I do concerning my health-care benefits?
Congratulations! You should schedule an appointment with a participating obstetrician as soon as possible (no referral required). Contact the Employee Benefits Division at 501-683-0260 or 866-451-8194 to enroll in the 'Mommy 2 B' program. Upon satisfactory completion of the inpatient copayment for delivery will be waived. Coinsurance will still be applied.

21. Are FluMist and flu shots covered?
Yes. When in-plan providers are used, they are covered 100%. The member may not be billed the difference in the billed and allowed amount. FluMist and flu shots are also covered at a participating pharmacy, and may be billed to the prescription card, with no copayment or coinsurance due.

22. Are diabetic supplies covered?
Yes. There is coverage for items and supplies such as insulin pumps and supplies, glucometers and supplies, and diabetic self-management training. Applicable charges may apply such as copayments and coinsurance. There is no contract maximum amount or limit for diabetic supplies. You may purchase your insulin and supplies at the pharmacy-all covered for just one copayment. Please refer to your Summary Plan Description for coverage details.

Other supplies or durable medical equipment (DME) items
Items must be obtained from an in-plan provider in order for the claim to be paid on the in-network benefit level. If an out-of-plan provider is used, the claim will be processed on the out-of-network benefit level. DME examples are crutches, wheel chairs, walkers, etc. Pre-certification by American Health Holding (AHH) is required for four categories of DME â€“ spinal cord stimulators, continuous glucose monitoring devices, defibrillator vests, and power mobility devices.

23. What is case management?
A case management program is a personalized, multidisciplinary process to assist patients and family members of patients who face catastrophic illnesses and long-term recoveries in meeting health needs. ARBenefits plan members case management services are provided by Arkansas Blue Cross and Blue Shield. Please contact customer service at 800-482-8416 to be directed to a case manager for your area.

24. Do I have coverage for prescriptions?
Please refer to your Summary Plan Description or Annual Benefits Guide to reference your plan prescription coverage.

PCP Selection

1. Am I required to select a primary care physician (PCP)?
ARBenefits members are not required to select a PCP (General Practice, Family Practice, Internal Medicine, Pediatrician); however, Health Advantage does encourage members to see a PCP for routine medical care and preventive health services and to coordinate health care.

2. If I decide to select a PCP, must I select the same PCP for all family members?
ARBenefits members do not need to select a PCP, and can see any participating PCP for medical care. On the gold plan you will pay the $25 PCP copayment for in a network PCP.

3. What is the proper procedure for seeing my PCP?
If you are a new member, we recommend that you contact your PCP office to schedule an appointment. You should also have your medical records transferred to your new PCP.

4. What if I become ill or am injured and my PCP office is not open?
Contact your PCP or the physician on call. He or she will instruct you on what to do. Since you are on the ARBenefits plan, you may see any PCP you want to see. However, if your problem is so severe that immediate medical care is needed, get help first at the nearest medical facility. Your PCP should be notified of any emergency care within 24 hours.

BlueCard Program

ARBenefits retirees with Medicare as their primary insurance may utilize any provider within the Medicare coverage area.

As an ARBenefits Health Advantage plan member, you have more freedom to choose the doctors and hospitals that best suit you and your family. Your coverage gives you a world of choices. Within the United States, you have access to more than 815,000 PPO doctors and hospitals. Outside the United States, access is available in more than 200 countries and territories around the world through the BlueCard Worldwide program. The BlueCard program gives you access to PPO doctors and hospitals almost everywhere, giving you the peace of mind that you'll be able to find the health-care provider you need.

With the BlueCard program, there are two methods to locate doctors and hospitals within the United States quickly and easily — the BlueCard number is located on the front of your ARBenefits ID card.

Call BlueCard Access® at 1-800-810-BLUE (2583) for the names and addresses of providers in the area where you or a covered dependent need care.
Visit Doctor and Hospital Finder at Blue National Doctor & Hospital Finder Web site to locate PPO providers, maps and directions.

Always use a BlueCard PPO doctor or hospital to ensure you receive in-network benefits.

Designed to save you money... In most cases, when you travel or live outside your local service area, you can take advantage of savings the local Blue plan has negotiated with doctors and hospitals in that state or country. For covered services, you should not have to pay any amount above the negotiated rates.

Take charge of your health wherever you are...
Within the United States:

Always carry your ARBenefits ID card.
In an emergency, go directly to the nearest hospital.
Refer to the BlueCard access number on the front of your card or the web address to locate a provider.
Call American Health Holding for pre-certification.
When you arrive at the PPO physician's office or hospital, show your ID card.

Around the World:

Verify your international benefits with Health Advantage before leaving the country.
Always carry your ID card.
Visit the World Wide directory to locate an in network provider while outside of the United States.
Visit www.BCBS.com to find an International Claim Form and to get more information regarding your out of country trip.
In an emergency, go directly to the nearest hospital.
Call the BlueCard World Wide Service Center at 1-800-810-BLUE (2583) or collect at 1-804-673-1177, 24 hours a day, seven days a week for information on doctors, hospitals, and other health-care professionals or to receive medical assistance services. An assistance coordinator, in conjunction with a medical professional, will help arrange a doctor's appointment or hospitalization, if necessary.
Call the BlueCard Worldwide Service Center when you need inpatient care. In most cases, you should only pay upfront the $250 copayment and 20 percent of the allowed charges. The hospital will submit the claim on your behalf.
You will need to pay upfront for care received from a doctor and/or a non-participating hospital. Contact Health Advantage upon return for assistance with claims payment.

Claims Processing

1. What is the time limit for filing a claim for benefits to Health Advantage?
A notice of claim must be made to Health Advantage by the member or the provider within 180 days of the date on which covered services were first incurred.

2. When will I receive a PHS and how will I know what amount I need to pay?
You will receive a Personal Health Statement (PHS) every two weeks on the claims that Health Advantage processes for a claim on you or your dependents/spouse on your contract. You should keep your PHS to compare it with the bill that you receive from the provider. Your minimum responsibility should match the amount requested from the provider. This may differ if the service is denied as a non-covered service or as a benefit limitation. If the amount indicated on your PHS does not match the amount billed by the provider, you may call the provider or Customer Service at Health Advantage.

3. How long should it take for me to receive a PHS from the date of my service?
Once the provider submits a claim, it should be processed within 30 days. This may be delayed if additional information is requested.

4. How can I find out if Health Advantage has processed a claim?
A PHS is mailed to your home every two weeks for the claims that have been processed. You may check the status of a claim online by going to My Blueprint and selecting "Check Claims Status." If the status shows "complete," the claim has been processed. If the status shows "in process," the claim has been received by Health Advantage, but final action has not been taken. From My Blueprint, you can also sign up for e-mail notifications when there is a PHS available. You also may call My BlueLine — an interactive voice response system — toll free, 24/7, at 1-800-482-8416.

5. How can I find out my financial responsibility for a claim?
A PHS is mailed to your home every two weeks for the claims that have been processed. Your copayment, deductible and coinsurance responsibility (if you have one) will be shown on the PHS. You may print a copy of the PHS for any claim that shows "complete" from My Blueprint under "Check Claims Status." You also may call My BlueLine — an interactive voice response system â€“ toll free, 24/7, at 1-800-482-8416.

6. Why does my provider send me a billing statement?
If the statement date is less than 30 days old from the date of service, it is possible that the billing statement may cross with the payment of the claim. If adequate time has been allowed for the processing of the claim, you should research the bill. If the claim has been processed and you received a PHS, the amount that the provider is billing you should be matched with the amount on the PHS that is listed as the member's responsibility. If the amount the provider is billing you is higher, or Health Advantage has not processed the claim, a call should be made to the provider's office. Explain the amounts shown on your PHS, ask them to research your bill, and ask them to verify the information filed on the claim. If the information filed doesn't match your ID card, the provider will need to file a corrected claim to Health Advantage. If you no longer have the PHS, you may view your claim information by using our online tools at www.HealthAdvantage-hmo.com. If the issue cannot be resolved, you or the provider can call the Customer Service Department at Health Advantage.

7. What do I need to look at closest when I receive a PHS?
The provider name and date of service should match a service that you received. If you did not receive this service, please call the provider. They may have filed an incorrect claim. If the date of service and provider information are correct, you should review the amount shown as your responsibility such as a copayment, coinsurance, deductible or denied charge. If you have questions or feel the amount is incorrect, you should call the Customer Service Department.

8. What if I receive a PHS and the claim has not been paid?
If your claim has not been paid and has been put in a "hold" status awaiting additional information or payment, your PHS will have a description of any additional information necessary for the claim to be processed and an explanation of why such information is necessary. If your claim has been denied, your PHS will have a reference to a specific plan provision on which the determination is based and a description of your plan's appeal process.

9. What should I do if any of my services were denied?
Review the service that was denied and reference the Exclusions or Benefit Limitations in the Summary Plan Description. If the service was denied correctly, you are responsible to pay the billed charge to the provider. If you feel the claim was denied in error, you may call the Customer Service Department at 1-800-482-8416. If you wish to appeal the denial of the claim, please follow the appeal guidelines listed in the Summary Plan Description.

10. What if I have a question about a PHS determination?
If you have questions about an PHS determination, you may contact Customer Service toll free at 1-800-482-8416 or write to: Health Advantage Customer Service, P.O. Box 8069, Little Rock, AR 72203. This informal review is not an appeal, nor a substitute for an appeal. Nor must you request an informal review in order to request an appeal. Not all information reviews can be processed by Health Advantage. In this case, the request will be forwarded to the plan administrator, Employee Benefits Division, for an appeal review.

Appeals

1. How do I appeal a claim or benefit determination?
If a claim for benefits is denied either in whole or in part, you may request a review of a denial of benefits for any claim or portion of a claim by sending a written appeal to Health Advantage, within 180 days of the denial. Your appeal should include your name, identification number, and reference to the denied claim. In preparing your request for review, you and your authorized representative have the right to examine documents relevant to your claim. You and your authorized representative may submit, with your request for review, any additional information relevant to your claim and may also submit issues and comments in writing. You will receive a final decision in writing within 30 days. the appeal is related to a service that required pre-certification from AHH, please call American Health Holding at 1-877-815-1017.

2. What if I disagree with a determination but am not able to file the appeal of a claim or benefit determination myself?
You may designate an authorized representative to represent you in filing an appeal of a claim or benefit determination. For information on designation of an authorized representative, please call Customer Service at 1-800-482-8416.

3. What if I have to pay for covered medical services or medical supplies?
If you make payment other than required copayments or coinsurance for services covered by Health Advantage, a claim for reimbursement may be made by submitting a copy of your receipt for payment for services received and a copy of the bill to Health Advantage. The request must include the member's ID number and be made within 180 days from the date on which expenses were first incurred. The request for reimbursement may be sent postage paid to: Claims, Health Advantage, Post Office Box 8069, Little Rock, AR, 72203-8069.

Other Insurance and Coordination of Benefits

1. Why do you want to know if I have other coverage?
A decision must be made as to which coverage is responsible for primary payment.

2. Does Health Advantage coordinate benefits?
Yes. If you or any of your dependents have other insurance coverage that provides benefits for hospital, medical, or other expenses, your benefit payments may be subject to coordination of benefits. Unless the member has Medicare primary, even if Health Advantage is not the primary carrier, you must still follow the plan guidelines in order for Health Advantage to coordinate benefits. It is the member's responsibility to ensure Health Advantage has a copy of the primary carrier's Explanation of Benefits and all itemized bills, and to inform Health Advantage of all changes in other insurance. If you need to update other insurance information, you may submit the information in writing, contact your employer benefits administrator, or call Customer Service.

3. If I have secondary coverage, how can I get a copy of my Personal Health Statement from Health Advantage?
A Personal Health Statement (PHS) is mailed to your home every two weeks for the claims that have been processed. You may also sign up for My Blueprint to view/print your PHSâ€™ or even elect to receive electronic notice when Health Advantage has finalized processing of a claim for you or a covered dependent.

4. How do I update other insurance information?
To update your Medicare information or other insurance information, you may complete the Coordination of Benefits Questionnaire and mail to: Health Advantage, Attn: Claims COB, P.O. Box 8069, Little Rock, AR 72203-8069. You may also call toll free 1-800-969-3983. You also must provide your Medicare information to the Employee Benefits Division. Obtaining Medicare may reduce your monthly premium.

Other Helpful Information

1. Contact Information


	Mailing address	P.O. Box 8069, Little Rock, AR 72203-8069

	Customer Service	1-800-482-8416

	Interactive Voice Response (available 24/7)	1-800-482-8416

	*My Blueprint*	Click on "technical support" for system issues, ID, password, and registration issues. Call 1-800-482-8416 if you have other questions.

	Trover (HealthCare Recoveries)	Call 1-800-685-4013 to report a motor vehicle accident or injury that includes third-party liability.

	COB information line	Call 1-800-969-3983 to report other medical or pharmacy insurance coverage or changes related to the other insurance information we have on file.

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