Type of Benefit
Maximum Benefit Payable
100 Days Maximum Services Inpatient Skilled Nursing, Inpatient Acute
Rehabilitation, Outpatient, Comprehensive Day or Half-Day Rehabilitation; Inpatient Long Term Acute Care; Mental Health Inpatient Care, Partial Hospitalization and Residential Treatment; Chemical Dependency, Inpatient Care, Partial Hospitalization and/or Residential Treatment
100 days combined maximum per calendar year
Mastectomy Supplies • Bras
• Breast Prosthesis
• Prosthesis as part of bra
• 2 per calendar year
• 1 per breast every two calendar years
Nutritional Consultants by a registered dietician 6 visits per calendar year
Prescription Drugs obtained at an Out-of-Network pharmacy $2,500 per calendar year
Supplies such as, but not limited to, diabetic and ileostomy. 60 days supply per order
Ultrasounds During Pregnancy 4 per pregnancy unless performed by a perinatologist Wig or hairpiece 1 wig or hairpiece (up to $300 benefit) following chemotherapy or radiation course of treatment
In order to help you contain your health care costs, the Trust limits the amount each individual must pay in copayments and
coinsurance during a Calendar Year. These limits are explained in the following charts:
Your Maximum Copayment and/or Coinsurance at In-Network Providers
Type of Service
Individual
Family
All other Covered In-Network Services, including prescriptions obtained from in-network retail or mail-order
pharmacies
$6,600 per
Calendar Year* Calendar Year*$13,200 per
Your Maximum Copayment and/or Coinsurance at Out-of-Network Providers
Type of Service
Individual
Family
All Out-of-Network Services $10,000 No Maximum
* After you have met the Maximum Copayment/Coninsurance, the Trust will pay 100 percent of the Eligible Medical Expenses (EME) for Covered In-Network services that you incur during the remainder of the Calendar Year.
Benefit Limitations/Maximums
The Trust provides an RN Case Manager to help you and your family members access services from the health care system. This assistance is called Case Management and is provided at no charge to the participant.
It is strongly recommended that you contact the Trust’s RN Case Manager if you and/or one of your covered Dependents have difficulties accessing the health care system, if you have been referred to an Out-of-Network Provider for your surgical procedure or surgical approach, or if you have been diagnosed with (or have been receiving treatment related to) the following:
▪ Cancer
▪ Cardiac/Cardiovascular Disease
▪ Diabetes
▪ High Risk Pregnancy (Also see Maternity/Pregnancy Services in this Medical chapter)
▪ Immunodeficiency Diseases/AIDS ▪ Kidney Dialysis ▪ Lupus ▪ Multiple trauma/accidents ▪ Respiratory/Lung Diseases ▪ Transplant Services
The Case Management Department is available to assist with exploring your options and accessing the health care system.
All Retiree Health Plan Participants and Dependents with a disabling condition are required to apply for Medicare and/or Medicaid within 31 Calendar Days of notification by the Trust of their potential eligibility for such programs. Once you receive a copy of your Medicare card, you must submit a copy of it to the Trust.
Contact the Case Management Department via telephone at 866-585-CARE (2273) or via e-mail at casemanager@ thtlvnv.org.
For Transplant Services, failure to contact the Case Management Department will result in NO benefits being paid by the Trust. (See Prior Authorizations in this Medical chapter.)
Case Management
Certain procedures and services require Prior Authorization to evaluate the medical necessity and appropriateness of the service. Accredited medical and behavioral health organizations conduct these reviews for the Trust.
Regardless of what the reviewing organization recommends, it is always up to you and your doctor to decide what, if any, care you receive. In the event you and/or your Physician do not agree with the authorization decision that you receive, your Physician may appeal the decision to the reviewing organization by providing (in writing) additional information to support the initial request for authorization.
You should advise your Physician to obtain Prior Authorization on your behalf if the services require it. If Prior Authorization is not obtained, benefits for the service may be greatly reduced or not paid at all.
Prior Authorization does not guarantee payment of benefits or determine what level of Plan benefits will apply. To verify eligibility and to determine benefit coverage, contact the Trust:
E-mail: [email protected]
Phone: 702-794-0272 or 800-432-5859
Mental Health and Chemical Dependency Services
Services Requiring Prior Authorization
• Inpatient Care, Partial Hospitalization, Residential Treatment and all psychiatrist, mental health nurse practitioner and Physician Assistants visits
• Group therapy visits, therapist visits and counselor visits after 24 sessions per year
Who to Contact Human Behavior Institute (HBI): 702-248-8866 or 800-441-4483
When to Call At least 48 hours prior to the service. In an emergency, contact HBI as soon as possible following the emergency.
Transplant Services
Services Requiring
Prior Authorization ALL Transplant Services
Who to Contact Teachers Health Trust RN Case Manager 866-585-CARE (2273) or [email protected] When to Call for
Transplant Services As soon as your Physician discusses the possibility of a transplant with you or you think you may need follow-up services from a previous transplant.
Failure to obtain Prior Authorization for Mental Health and Chemical Dependency Services will result in NO benefits being paid for those services!
Failure to coordinate Transplant Services through the Trust’s RN Case Manager will result in NO benefits being paid for those services! Please see the Transplant Services section for more information.
All Other Services Requiring Prior Authorization
Services Requiring Prior Authorizations
• Air Ambulance
• Blepharoplasty (eyelid surgery)
• Botox Injections
• Breast Surgery
• Continuous Glucose Monitoring Device
• Cosmetic Surgery
• CT Scan
• Dialysis
• Durable Medical Equipment (valued at $500 or more)
• Durable Medical Equipment repair or replacement
• Endoscopy
• Extended Network Benefit
• Genetic Testing
• Hernia Repair
• Home Health Care
• Hospice Care
• Hyperbaric Oxygen Therapy (after 30 treatments)
• Infusion Services
• Inpatient Admissions
• MRIs and MRAs
• Nerve Conduction Studies/EMGs
• Oral Appliance for Sleep Apnea
• Out-of-Network Laboratories
• Pain Management (Nerve Blocks)
• PET Scans
• Sclerotherapy (Vein Surgery)
• Skilled Nursing Facility
• Testosterone Pellets/Insertion of Pellet
• Transplant and Follow Up Transplant Services
• Virtual Testing (when diagnosis is present)
Who to Contact
Health Care Partners Fax: 702-318-2404 Phone: 702-216-3361 Toll-free: 877-823-0485
When to Call Urgent/Emergency Care: Within one (1) day of the service or admission to a Hospital. Non-Urgent/Non-Emergency Care: As soon as possible prior to the service.
Failure to obtain Prior Authorization through Health Care Partners for the above-listed services may result in benefits being greatly reduced or not paid at all.
The reviewing organizations are available by telephone or fax 24 hours a day, seven days a week to accept requests for Prior Authorization.
The Trust processes all medical claims for RETIREE Medical Plan Participants. Most Providers will file your claim for you and you will not need to provide them with a claim form. If your Provider does require a claim form—and/or if you must file the claim yourself—you may obtain one at the Trust office or online from the Trust’s website at www.teachershealthtrust.org.
Your claim for benefits must include the following:
▪ ID number of the Covered retiree (not the Dependent);
▪ Name and birth date of patient;
▪ Diagnosis code;
▪ Date of service;
▪ Procedure codes/NDC codes; and
▪ Provider’s signature.
Generally, your claim for benefits must be submitted directly to the Trust. If the Trust is the secondary insurance carrier, you or your Provider should submit your claims to both your primary carrier and the Trust. After the primary carrier has processed the claim, you (or your Provider) should submit a copy of the primary carrier’s Explanation of Benefits (EOB) to the Trust.
Claims must be received in the Trust office no later than twelve months following the date of service.
CLAIMS NOT RECEIVED IN THE TRUST OFFICE WITHIN TWELVE MONTHS OF THE DATE OF SERVICE WILL BE DENIED!!!
Completed claim forms and attachments must be mailed to:
Teachers Health Trust
P.O. Box 96238
Las Vegas, NV 89193-6238
If claims and/or attachments require foreign language translation, payment of the fee for that service is the responsibility of the Participant.