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Arkansas State and Public School Employees

ASE/PSE Frequently Asked Questions

For additional information on the following subjects, please refer to your Summary Plan Description.

Eligibility and Enrollment

When can I enroll in the plan?

Arkansas State Employees Open Enrollment period is September 1 through September 15, 2017, for changes for the 2018 plan year. Public School Employees Open Enrollment is set to begin October 1 through October 15, 2017, for changes effective January 1, 2018.

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.

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:

  1. Are they less than age twenty-six (26)?
  2. Are they a qualified disabled dependent, and have they been medically certified as totally disabled due to mental or physical incapacity?
  3. 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.

Contact the Employee Benefits Division at 877-815-1017 for more information.

When is my newborn covered?

Newborn children can be added within 60 days of the date of birth. The Election form requesting coverage for your newborn must be submitted through the Employee Benefits Division.

What is a qualifying event for COBRA coverage?
  1. Termination of an enrolled employee's employment (other than for gross misconduct) for any reason (layoff, resignation, retirement, etc.).
  2. Reduction of work hours.
  3. Death of the covered employee.
  4. Divorce or legal separation from the covered employee.
  5. Dependent child ceasing to meet eligibility requirements.
  6. Retiree or retiree's spouse or child loses coverage within one year before or after the commencement of proceedings under Title 11.
  7. When dependent loses coverage due to covered employee becoming entitled to Medicare.
What is a certificate of credible coverage (COCC)?

A Certificate of Credible Coverage (COCC) lists your coverage with ARBenefits the initial effective date to your termination date. This certificate is generated after your policy is terminated. Contact Employee Benefits Division if you need a COCC.

Health Plan Information

Do I need 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, make sure the information on your ID card is correct and that all providers have the correct date of birth and the spelling of your name as it appears on your card.

What if I lose my ID card?

Contact the Employee Benefits Division (EBD) at 877-815-1017 to order a replacement card.

What is the difference between in-network and out-of-network services?

In-network services are covered services or supplies a member receives from a contracted physician/provider. Out-of-network services are covered services or supplies a member receives from a non-contracted physician or provider. Non-contracted providers may balance bill the difference between the billed charges and the allowable charges.

Does Health Advantage provide online services for members?

Yes. HealthAdvantage-hmo.com provides:

  • Health plan information: General information about the health plan, referral information, preventive health information, BlueCard Program, and My Blueprint, which allows you to view claims 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.
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.

What is a deductible?

A deductible is a specific amount that a member must pay out of pocket each year before the plan begins to pay its portion.

What is a copayment?

A copayment is the predetermined fixed dollar amount a member must pay to receive a specific service. Copayments will apply to the True Out-Of-Pocket (TrOOP) limit.

What is coinsurance?

Coinsurance is defined as a percentage of the allowable charge that a member pays for a service after any deductible and copays are applied.

What is applied to the annual maximum out-of-pocket?

Eligible coinsurance for medical services.

What is applied to the true out-of-pocket (TROOP) maximum?
Medical services coinsurance, deductible amounts, and copayments apply.
How can I be sure I'm receiving 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 contacting Customer Service to verify whether a specific provider is in-network. Remember, click on the provider directory listed as ARBenefits. If traveling or living out of state, call 1-800-810-BLUE or use the find a doctor tool to find participating providers.

Why would a health plan ask for additional information, such as medical records?

Some procedures are only covered when specific criteria are met for coverage. Medical records can be requested for the review of coverage criteria.

What are my wellness benefits?

Your ARBenefits Plan provides some services recommended for the prevention and early detection of disease. You may review the Preventive Services or the Immunization Benefit Coverage policies at arbenefits.org under Coverage Policies for services received prior to June 1, 2014, and see Health Advantage coverage policy for services beginning June 1, 2014, to the present.

Which services need prior approval?

The Arkansas Employee Benefits Division (EBD) has contracted with a third-party vendor, ActiveHealth for School & State members, not affiliated with Arkansas Blue Cross and Blue Shield or Health Advantage, for the Arkansas State and Public School employees, to provide utilization management services that include prior approval and concurrent review. Services that require prior approval from ActiveHealth for School & State members include but are not limited to:

  • All inpatient admissions
  • Inpatient rehabilitation
  • Cognitive rehab
  • Home infusion therapy
  • Residential treatment
  • Specific therapy
  • Home nursing visits
  • MRI/MRA
  • Skilled nursing facilities
  • Pet scan
  • 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 ActiveHealth for School & State members at 1-877-815-1017 for prior approval for you to receive these types of services.

Transplants need to be prior approved by ActiveHealth for School & State members at 877-815-1017.

Do I need a referral to get 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.

If I'm on vacation 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, 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. To find a BlueCard healthcare provider outside Arkansas, visit the National Doctor & Hospital Finder.

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.

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
What about 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, wheelchairs, walkers, etc. Prior approval by ActiveHealth for School & State members is required for four categories of DME: spinal cord stimulators, continuous glucose monitoring devices, defibrillator vests, and power mobility devices.

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. Please contact ActiveHealth for School & State members at 877-815-1017 to be directed to a case manager for your area.

Do I have coverage for prescriptions?

Refer to your Summary Plan Description at arbenefits.org for complete prescription information, including formularies, prior approval and exclusions.

Public School retirees with Medicare coverage do not have a prescription drug benefit with this plan.

PCP Selection

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 healthcare.

BlueCard Program

What is this 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. Within the United States, you have access to more than one million PPO doctors and hospitals. Outside the United States, access is available in more than 200 countries and territories around the world through the Blue Cross Blue Shield Global® Core 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 healthcare 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.
  • To find a BlueCard healthcare provider outside Arkansas and to view a map with detailed driving instructions, visit the National Doctor & Hospital Finder. 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 Blue Cross Blue Shield Global® Core directory to locate an in network provider while outside of the United States.
  • Visit 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 Blue Cross Blue Shield Global® Core 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 healthcare 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 Blue Cross Blue Shield Global® Core 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

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.

When will I receive a PHS and how will I know what amount I need to pay?

You will receive a PHS every two weeks when claims are processed for 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. 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.

How long should it take to receive a PHS from the date my service?

If your medical service provider files the claim right after your service, and there are no delays in processing, you should receive a PHS in approximately 4 weeks. Once the medical service provider submits a claim, it should be processed within 30 days. This may be delayed if additional information is requested.

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. 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 toll free, 24/7, at 1-800-482-8416.

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 bills 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 in My Blueprint. If the issue cannot be resolved, you or the provider can call the Customer Service Department at Health Advantage.

What if I receive a PHS and the claim has not been paid?

If your claim has not been paid, it is either denied, waiting for more information from you or the medical provider, or applied to your deductible. The reason for non-payment will be listed with the claim detail information on the PHS. If you are unsure how to read it, or question the reason for non-payment, contact customer service.

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, follow the appeal guidelines listed in the Summary Plan Description.

What if I have a question about a PHS determination?

If you have questions about a claim determination on your PHS, you may contact Customer Service toll free at 1-800-482-8416 to discuss the claim. If the Customer Service Representative cannot resolve the issue to your satisfaction you may write to: Health Advantage Customer Service, P.O. Box 8069, Little Rock, AR 72203 to request a re-review of the claim. This informal review is not an appeal, nor a substitute for an appeal. Formal appeals must be submitted in writing to the plan administrator, Employee Benefits Division, Attn: Appeals, P.O. Box 15610, Little Rock, AR 72231.

Appeals

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 if the appeal is related to a service that required pre-certification from AHH, please call American Health Holding at 1-877-815-1017.

What if I disagree with a determination but am not able to file the claims appeal 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 the Employee Benefits Division at 877-815-1017.

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

Why do you want to know if I have other coverage?

A review must be conducted to determine the order each carrier should process claims.

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. 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.

If I have secondary coverage, how can I get a copy of my Explanation of Benefits 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 PHS or even elect to receive electronic notice when Health Advantage has finalized processing of a claim for you or a covered dependent.

How do I update other insurance information?

To update your Medicare information or other insurance information, you may complete the coordination of benefits questionnaire [pdf] 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

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: Select need help for system issues, ID, password, and registration issues. Call 1-800-482-8416 for help with other questions.

Equian|Trover Solutions (HealthCare Recoveries): Call 1-800-945-0323 to report a motor vehicle accident or injury that includes third-party liability.