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Equity-League Health Trust Fund Frequently Asked Questions

Eligibility under the Health Plan

How is Health Fund eligibility established?
How many benefit credits must I earn in order to qualify for health coverage through covered employment?
Will I receive double the amount of weeks when my employer-paid health coverage is determined if I work for two different employers during the same week ending period?
Do I have to pay a premium in order to receive my health coverage?
What happens if I elect coverage and make one quarterly premium payment but don’t pay for the rest of it? Do I get benefit credits (weeks) back?
I earned more than 12 benefit credits, but less than 20 over a 12 month accrual period, and received a statement saying I was eligible for 6 months of coverage beginning October 1. I am currently working and know that I will earn additional benefit credits that will raise my total to 20. Since I’d rather have 12 months of Health Fund coverage, can I pass on coverage now, and instead wait until I have enough benefits credits to qualify for 12 months of coverage?
If I qualify for health coverage, but don’t pay for the first quarter, when do you next check my eligibility: three months later or 12 months later?
If I am covered by employment under an HMO or the Point of Service (POS) Medical Plan administered through Cigna, do I have to pay the $100 premium for either one?
Will I receive a bill for the $100 premium?
When is my $100 premium payment due?
How can I pay my $100 premium?
Can I pay more that $100 in advance?
Does the producer pay for the coverage of my dependents?
Does the $100 premium also cover my dependents?
Will I be sent a bill to apply for extended health coverage when my health coverage through covered employment runs out?
Who should I contact if I have a problem with one of the insurance companies?


Self-Pay health coverage under the Plan - COBRA, Vested Beyond COBRA and Medicare Supplemental

If my coverage from employment ends, how long can I remain on self-pay under COBRA?
Under COBRA do I have a grace period for paying my premium once my employer paid coverage runs out?
Will my claims be covered during the grace period?
When my coverage from COBRA ends, how long can I remain on self-pay?
When do I qualify for Medicare Supplemental coverage?
Do I have to pay the $100 premium in addition to the premium for COBRA, Vested Beyond COBRA or Medicare Supplemental coverage?
If I fail to pay the required premium for any of these types of self-pay coverage, may I come back into the plan at any time?

Am I locked into using OAP providers exclusively?
Are there surgeons in the OAP network?
If I want to see a OAP specialist, do I have to clear it with anyone first?
Exactly how much is the OAP discount?
I'm in an HMO, but now that the OAP is available, the Indemnity Medical Plan is looking better and better. If I can't decide before the special Open Enrollment ends, can I switch to it later on?
Will Major Medical cover more expenses under the OAP?
When I take my daughter to her pediatrician for check-ups, it's cover 100% under Major Medical, so what's my incentive to switch to a OAP doctor?
My partner's enrolled under my medical coverage. Does he get the OAP benefit, too?
Do I have to use a OAP provider to get benefits?
Does the OAP apply to prescription drugs?
Can I go to my own non-OAP doctor for my routine medical care and to a OAP doctor for, say, speciality care?
I'm on the road a lot. Let's say I get the flu and want to see a doctor. How do I find out who the local OAP doctors are?
Do OAP co-pays count toward meeting the $5,000 annual out-of-pocket coinsurance maximum?
Can any provider belong to the OAP?
My wife and four kids are in my medical plan. Does that mean each of us has to meet the $700 annual deductible?
Can retirees use the OAP?
Are there OAP providers everywhere?
If it turns out my doctor isn't in the OAP, can she get in?
How will a OAP doctor know I'm entitled to OAP benefits?
What if I don't get my new ID card by the start of my eligibility period?

DENTAL (coverage under the POS CIGNA and HMO plans)


When am I eligible for the Dental Care Plan?
If I qualify for health coverage, but do not make the $100 premium can I still elect to self-pay for dental coverage?
What type of plan options are available under the CIGNA Dental Plans?
What is the  quarterly cost that I am responsible for between the DHMO, and PPO plans?
Do I have a deductible under the CIGNA Dental Plan?


VISION (coverage under the Indemnity and HMO plans)


When am I eligible for the Vision Care Plan?
How am I covered under the Davis Vision Plan (Vision Care)?
Are there any optional frames, lens types, or coatings available?
Am I still eligible for benefits if I go outside the Davis Vision Network?
Do I have a deductible under the Davis Vision Plan (Vision Care)?
How often am I eligible for Vision Care Eye Examinations?
How often am I eligible for Eye Glasses and Contact Lenses?






Eligibility under the Health Plan

How is Health Fund eligibility established?

Health Fund eligibility is established by earning enough benefit credits (that is, working the required number of weeks) during a 12-month period known as the Accrual Period. Benefit credits earned in an Accrual Period are what enable you to qualify for coverage for a corresponding Benefit Period, which begins the next calendar quarter (three months after the Accrual Period ends). There’s a three month gap between an Accrual Period and a Benefit Period, know as the Waiting Period.

Health Fund Accrual Periods

12 Months Counting From
First Sunday In:	To Last Sunday In:	3 months Counting From		6 or 12 Months of Coverage Starting On:
October	September	October	December	January 1
January	December	January	March	April 1
April	March	April	June	July 1
July	June	July	September	October 1

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How many benefit credits must I earn in order to qualify for health coverage through covered employment?

In order to qualify for plan eligibility, you must have at least 12 benefit credits in the previous 12 month accrual period to qualify for SIX (6) months of coverage. If you attain 20, or more benefit credits in the previous 12 month accrual period, you will qualify for TWELVE (12) months of coverage.

For example, if John Doe had 12 weeks benefit credits between the first Sunday in July of a year and the last Sunday in June of a year, he would qualify for a SIX months of coverage effective October 1. If John attained 20 or more benefit credits during this same period, then he would qualify for TWELVE month effective October 1. The work does not have to be consecutive nor does it have to be under the same contract but it does have to be under a contract that requires the full health rate contributions to the Health Fund. A contract that pays only the worker's compensation does not count toward Health Fund eligibility.

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Will I receive double the amount of weeks when my employer-paid health coverage is determined if I work for two different employers during the same week ending period?

Yes, as along as the weeks completed from both employers are within a required accrual period to determine an eligibility benefit period.

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Does the producer pay for the coverage of my dependents?

No. You must pay an additional premium for dependent coverage.

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Will I be sent a bill to apply for extended health coverage when my health coverage through covered employment runs out?

Yes, you will be billed automatically, based on COBRA law, to the address we have on file. The premium billed will be for a period of three months.

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Who should I contact if I have a problem with one of the insurance companies?

You should contact the Fund Office immediately.

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Self-Pay health coverage under the Plan - COBRA, Vested Beyond COBRA and Medicare Supplemental

If my coverage from employment ends, how long can I remain on self-pay under COBRA?

Participants may remain on self-pay for 18 months. Participants who have been awarded a Disability Award by the Social Security Administration may remain on self-pay for 29 months. This is part of the provisions of the COBRA Law and is referred to as the COBRA period.

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Under COBRA do I have a grace period for paying my premium once my employer-paid coverage runs out?

When your coverage by employment first runs out you have 60 days to decide if you wish to continue your policy by self-pay. You must fill out the COBRA election form and return it to the Equity-League Fund Office. Thereafter, you have a 45-day grace period from your COBRA Election date, to submit the premium for your first quarter under self-pay. Once your initial premium is received, you will be billed automatically on a quarterly basis and you will have a 30-day grace period.

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Will my claims be covered during the grace period?

After your coverage by employment terminates, the COBRA election form is mailed along with a premium notice. Once the COBRA election form and the premium payment is received indicating that the member would like to continue by self-pay, your coverage will be retroactive to the end of your coverage by employment and your claim will be processed.

For more extensive information regarding COBRA, please go to the COBRA Entitlement section on the website.

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When my coverage from COBRA ends, how long can I remain on self-pay?

Participants who are vested with 10 years of service under the Pension Plan may remain on self-pay indefinitely.

When do I qualify for Medicare Supplemental coverage?

If you continue to self-pay continuously as a Vested Beyond COBRA participant, and once you are eligible for benefits under Medicare, you will be entitled to Medicare Supplemental coverage at that time. The Fund will coordinate your benefits with Medicare. Your primary level of benefits is Medicare and the Fund will be secondary which results in a lower premium.

HMO

What is an HMO?

An HMO (Health Maintenance Organization) is an insurance company that has established a contract with a network of providers (doctors, labs, pharmacies, hospitals, specialists, etc.) to provide health care to a subscriber. The HMO charges a fixed pre-determined price per participant and in exchange provides health care services as often as needed.
What is an HMO?

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How is an HMO different from the POS CIGNA Plan?

The HMOs do not have a deductible. The HMOs provide in-network benefits only by either paying a co-pay or no co-pay at all (this varies by each HMO) as opposed to the POS CIGNA Plan, which provides in and out-of-network benefits. For in-network benefits, there is a co-pay of $25 for each doctor visit. When you go out-of-network, there is a 30% co-pay up to reasonable and customary charges that has to be paid after the plan deductible has been satisfied. However, the HMO requires you to choose a Primary Care Physician (PCP) who is responsible for making all referrals to specialists. When you are with the POS CIGNA Plan, you do not have to choose a Primary Care Physician, you may go to any doctor, and you may go to a specialist without a referral.

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Where are the HMOs located?

Equity League has contracts with HMOs in:

Southern California (Kaiser Permanente)
Northern California (Kaiser Permanente)
Minnesota (Medica)
New York (HIP of New York)
Washington, DC (Kaiser Permanente)

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I need to contact my HMO. How can I reach them?

Following are the available Member Service telephone numbers and website addresses for the HMO's with whom Equity League has a contract:
HMO Member Services Website

Kaiser 800 464-4000 www.kaiserpermanente.org/locations/california/index.html
(Southern CA)
Group # 000109137-0000

Kaiser 800-464-4000 www.kaiserpermanente.org/locations/california/index.html
(Northern CA)
Group # 000002861-0000

Kaiser 800-777-7902 www.kaiserpermanente.org
(Mid Atlantic)
Group # 2863-00

HIP 800-HIP-TALK www.hipusa.com
(New York)
Group # 92NY

Medica 612-992-2200 www.medica.com
(Minnesota)
Group # 62040

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When can I enroll in an HMO?

o You can enroll in an HMO when you first become eligible for Equity-League benefits.
o You can enroll in an HMO during "Open Enrollment". HMO applications must be submitted during the month of November each year (the coverage will be effective the following January 1).
o If you move permanently into a new area that has an HMO, you may enroll in the HMO effective with the first date of the next month after notification of the Fund. A permanent move is a move in which you plan to live in the new location for 9 continuous months or more.

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If I'm with the POS CIGNA Plan now, when can I switch to an HMO?

o You can change to an HMO during "Open Enrollment." HMO applications must be submitted during the month of November each year (the coverage will be effective the following January 1).
o If you move permanently into a new area that has an HMO, you may enroll in the HMO effective with the first date of the next month after notification of the Fund. A permanent move is a move in which you plan to live in the new location for 9 continuous months or more.

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I'm covered by an HMO now, when can I switch to the POS CIGNA Plan?

o You can change to the POS CIGNA Plan during "Open Enrollment." A letter must be sent during the month of November of a given year to: HMO Coordinator, Equity League Health Trust Fund, 165 West 46th Street, New York, NY 10036. The effective date of the change to the Indemnity Plan would be January 1 of that year.
o If you have a permanent move out of your HMO service area, you may change to the Indemnity Plan effective with the first day of the next month following sending written notice of a permanent move to: HMO Coordinator, Equity League Health Trust Fund, 165 West 46th Street, New York, NY 10036. A permanent move is a move in which you plan to live in the new location for 9 continuous months or more.
o If you have an extended tour, you may change to the Indemnity Plan effective with the first day of the next month following sending written notice of a permanent move to: HMO Coordinator, Equity League Health Trust Fund, 165 West 46th Street, New York, NY 10036. An extended tour is a tour in which you will be in for 9 months or more.

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Can I cover my dependents under the HMO Plan?

Dependents can be covered under the HMO Plan. Dependent coverage is available if one of the following conditions is met:

o Dependent coverage can be applied for at the same time that a member becomes covered by employment under an Equity contract provided that the member was not already covered as a result of previous Equity employment.

o Members who are already covered under the hospital and/or medical plans on an individual basis may apply for dependent coverage in the hospital and/or medical plan, whichever coverage they have at the time of the application, within 31 days from the date of marriage of the member or date of birth of the member's newborn child. The effective date of the coverage will be the first of the month in which the event occurred provided the appropriate premium is paid for that month.

o Members who are already covered under the hospital and/or medical plans on an individual basis on January 1st of each calendar year may apply for dependent coverage on the hospital and/or medical plan, whichever coverage they have at the time of application, to be effective January 1st. The Fund Office must receive the application no later than November 30st.

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Can my domestic partner be covered?

Yes, you can enroll your domestic partner under your Equity-League benefits through the HMO provided that:
1) You assume the cost of the insurance premium for your domestic partner (rates may be obtained from the plan office), and
2) You complete the appropriate HMO application or change form, and
3) The participant must complete and NOTARIZE the forms labeled “Equity-League Pension and Health Fund Affidavit of Domestic Partnership” and “Attachment 1, Declaration of Financial Interdependence.” Please note that if the state or municipality in which you reside provides for the registering of Domestic Partners, you must register with such state or municipality and also attach a copy of the registration to the Domestic Partner Affidavit.

If you submit proof of Domestic Partner registration or a certificate of marriage (from a jurisdiction legalizing same-sex marriage), you do not need to submit the Declaration of Financial Interdependence or further proof of financial interdependence.

A domestic partner can be added as a dependent:
o When you become newly eligible
o During "Open Enrollment" (November of each year with an effective date of the following January 1).

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My doctor is not part of the HMO. Can I still enroll?

Yes, you can still enroll, but you will still have to choose a "Primary Care Physician" who is part of the HMO's network. If you choose to see a "non-HMO" doctor, you will be financially responsible for all charges incurred, including lab, drugs, etc.

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Where do I obtain the enrollment material?

o The enrollment material is obtained under the HMO Summary Of Benefits
o If you will be newly eligible shortly (and you reside in an HMO service area), the HMO enrollment information will be sent to you automatically approximately six weeks prior to the effective date.
o If you will be enrolling in an HMO or adding a dependent during the next "Open Enrollment" period, please contact the HMO Coordinator at Equity League anytime from November 1 to November 30 of the year (the effective date for the change will be January 1 of that same year).

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Where do I send my completed enrollment form?

The completed enrollment form should be sent to: HMO Coordinator, Equity League Health Trust Fund, 165 West 46th Street, New York, NY 10036.

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An HMO already covers me and I have a question regarding benefits. Where do I find answers?

Call the Member Services phone number on your card. If after contacting the Member Services department of your HMO you have not received an answer to your question, please contact the HMO Coordinator at Equity League (800) 344-5220 or (212) 869-9380.

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I'm in an HMO and I'm moving out of the area. What are my options?

If you are moving to another HMO service area, you have two options:
o You may change to the HMO at the new address effective with the first day of the next month (after completing the appropriate HMO enrollment application).
o You also have the option to transfer to the Indemnity Plan effective with the first day of the next month (after sending a notification of a permanent move letter to: HMO Coordinator, Equity League Health Trust Fund, 165 West 46th Street, New York, NY 10036).

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I'm in an HMO and I'm going to be on an extended tour (9 months or more). What are my options?

We strongly advise that you transfer your benefits to the POS CIGNA plan, since the POS CIGNA plan will allow you to seek medical care with any doctor in the country.
o You can transfer to the POS CIGNA plan effective with the first day of the month following your sending a notification of an extended tour letter to HMO Coordinator, Equity League Health Trust Fund, 165 West 46th Street, New York, NY 10036.
o You can, of course, remain on the HMO and be covered by the HMO only for emergency treatment. Each HMO has coverage for emergency care if you are away from your service area. Generally the care is covered by the HMO if:
a. the condition is defined as an emergency by the HMO,
b. you have notified the HMO of the condition within the HMO's stipulated time frame, and
c. you have received approval by the HMO. (At no time can you expect the HMO to cover follow-up care, or care for a condition that the HMO considers is not an emergency).
Any charges not covered by the HMO as an emergency benefit you must pay out of pocket.

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I'm in an HMO and I'm going to be away from home 4 months. What are my options?

We cannot generally enroll you in the Indemnity plan unless you will be away for 9 months or more.
o If you will be leaving in January of a year, you can use "Open Enrollment" to change your benefits to the Indemnity plan. Should you change to the Indemnity plan during "Open Enrollment", you must remain on the Indemnity plan until the next "Open Enrollment" of the following year.
o If you will be away from home less than 9 months and you are not leaving in July of a year, you must remain on the HMO. We advise you to take with you your HMO insurance card and review your HMO's procedure for emergency care when you are away from your HMO service area.

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I'm in an HMO and I just don't like it. What are my options?

If you have been diagnosed with a serious illness, please see the next question. Otherwise you must wait until the next "Open Enrollment" period to change (November of each year, with an effective date of the change being the following January 1).

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I'm in an HMO and I've been diagnosed with a serious condition and I'm not confident that the HMO can provide me with the care I need. What are my options?

You may write a "special circumstances" letter requesting a transfer of you benefits to the Indemnity Plan (Cigna) Please address your letter to:
Mr. Arthur Drechsler
Executive Director
Equity League Health Trust Fund
165 West 46th Street
New York, NY 10036

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Point Of Service (POS) Medical Plan Administered through CIGNA

What is the POS CIGNA Plan?

The POS CIGNA Plan is the default plan that is offered through Equity-League. If you live in an area where an HMO is available and you do not choose an HMO, the POS CIGNA Plan is the plan that you are enrolled in automatically in the event you pay the $100 premium.. The POS CIGNA Plan is made up of a hospitalization policy and a major medical policy through CIGNA (Connecticut General Life Insurance Company.) Hospitalization services include, but are not limited to, the facility charges for emergency room visits, ambulatory surgery, in-patient medical admissions, etc. Major Medical services include professional fees, diagnostic testing, etc. Coverage for prescription drugs is provided by CIGNA (Connecticut General Life Insurance Company) participating pharmacies. Vision care is administered through Davis Vision, Inc. Dental coverage will be available to participants through a voluntary self-pay basis effective through the Connecticut General Life Insurance Company (CIGNA). 

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Can I cover my dependents under the POS CIGNA Plan?

Dependents can be covered under the POS CIGNA Plan. Dependent coverage is available if one of the following conditions is met:
o Dependent coverage can be applied for at the same time that a member becomes covered by employment under an Equity contract provided that the member was not already covered as a result of previous Equity employment.
o Members who are already covered under the hospital and/or medical plans on an individual basis may apply for dependent coverage in the hospital and/or medical plan, whichever coverage they have at the time of the application, within 31 days from one of the qualifying events listed under the special enrollment situations section in the Health Summary Plan Description. The effective date of the coverage will be the first of the month in which the event occurred provided the appropriate premium is paid for that month.
o Members who are already covered under the hospital and/or medical plans on an individual basis on January 1st of each calendar year may apply for dependent coverage during the Annual Open Enrollment, November of each year, to be effective January 1st. The Fund Office must receive the application no later than November 30th.

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Can I cover my domestic partner under my policy?

Domestic partners can be covered as dependents under the POS CIGNA Plan. Dependent coverage can be applied for at the same time that a member becomes covered by employment under an Equity contract provided that the member was not already covered as a result of previous Equity employment. Members who are already covered under the hospital and/or medical plans on an individual basis on January 1st of each calendar year may apply for dependent coverage on the hospital and/or medical plan, whichever coverage they have at the time of application, to be effective January 1st. The Fund Office must receive the application no later than November 30th. The following applies:
1) You assume the cost of the insurance premium for your domestic partner (rates may be obtained from the Fund Office), and
2) The participant must complete and NOTARIZE the forms labeled “Equity-League Pension and Health Fund Affidavit of Domestic Partnership” and “Attachment 1, Declaration of Financial Interdependence.” Please note that if the state or municipality in which you reside provides for the registering of Domestic Partners, you must register with such state or municipality and also attach a copy of the registration to the Domestic Partner Affidavit.

If you submit proof of Domestic Partner registration or a certificate of marriage (from a jurisdiction legalizing same-sex marriage), you do not need to submit the Declaration of Financial Interdependence or further proof of financial interdependence.

A domestic partner can be added as a dependent:
o When you become newly eligible
o During "Open Enrollment" (May of each year with an effective date of the following July 1).

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If I am self-paying, do I have to pay for both the hospitalization and major medical portions of the plan?

A member on self-pay may MUST pay for both the hospitalization and major medical plan. If a member is not interested in self-paying for coverage, he/she may choose not to pay the premium and thereby terminate his/her policy. Please note that if a policy is terminated, the only way to pick up coverage through Equity-League again is to re-qualify by working under covered employment based on the current eligibility requirements of the Fund.

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What services are covered under the POS CIGNA (Connecticut General Life Insurance Company)?

The CIGNA Insurance Company covers professional fees (physicians, surgeons, etc.), private duty nursing (RN or LPN), X-rays, laboratory tests, durable medical equipment, ambulance service, medical supplies (dressings, casts, splints, etc.), non-dental prosthetic appliances, etc. CIGNA will also cover facility charges for in-patient medical admissions, in-patient treatment of mental and nervous disorders, in-patient treatment for alcoholism and substance abuse, out-patient treatment of alcoholism and substance abuse, out-patient sudden and serious illness, accidental injury, surgery, pre-surgical testing, home health care, chemotherapy, radiation therapy, mammography, etc.
Please refer to the Summary Plan Description for full details on covered charges and exclusions.

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Is Pre-Admission Certification required for In-Patient Hospital visits under the POS CIGNA plan?

 Yes. You must contact the hospital that you will be having your procedure done within 72 hours prior to your admission  into your hospital.

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What is the rate of reimbursement for covered services under the hospitalization Plan?

CIGNA at contracting facilities are generally payable at 100% of covered charges. Please be aware that if you go to a NON-PARTICIPATING hospital for a NON-EMERGENCY admission, then you will be responsible for 30% of the cost of the facility charges. Rates may vary for home health care or facilities other than hospitals, so please contact the Fund Office for more specific information. Please note that this benefit is for the facility charge only. Professional fees, in or out of the hospital, are covered under CIGNA through the Major Medical portion of the health plan.

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Is Home Health Care covered under the POS CIGNA Plan?

CIGNA provides Home Health Care through the hospitalization plan. Home Health Care must be in lieu of hospitalization. Benefits are provided in your home as part of a treatment plan approved by your physician for a condition that would otherwise require you to be admitted to a hospital or a skilled nursing facility. Home Health Care is limited to 200 days per calendar year. Please be aware that if you elect to use an out-of-network service, you will be subject to a $50.00 deductible, plus 30% of charges. The $50.00 deductible will be inclusive of the overall $700.00 out-of-network plan deductible. Also, a maximum of 16 hours counts as 1 day under this benefit.

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What is the rate of reimbursement for covered services under the POS CIGNA Plan?

The POS CIGNA Plan will reimburse most benefits at a rate of 70% of reasonable and customary after an annual deductible of $350.00 has been satisfied.

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What is a deductible?

The deductible is the amount of covered expenses that you pay before major medical benefits are payable. The deductible is payable only once in each calendar year for each individual. The deductible for one indivudial is $350. There is a $700 Maximum for Family deductible (At least one family member will have to meet the $350 deductible. The balance of the deductible can be a combined total).

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Does the deductible run per calendar year or by year of eligibility?

The deductible is accumulated by calendar year. This means that regardless of eligibility your deductible begins anew as of January 1 of each year. A "carry-over" provision WILL NOT apply from one year to another.

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Do I have a lifetime maximum reimbursement?
 
The POS CIGNA Plan does not have a maximum lifetime limit on reimbursement for either the hospital, or major medical portion of the health plan.

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What is "reasonable and customary"?

Reasonable and customary is the usual charge made by a person, group or entity which renders or furnishes the services, treatments or supplies that are covered under the major medical plan. Reasonable and customary is defined as the amount being charged for a particular service by 80% of the doctors in the same area.

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Does the POS CIGNA PLAN ever pay 100% for out-of-network major medical services?

The POS CIGNA Plan Life Insurance Company pays 100% of reasonable and customary after a member exceeds the $5000.00 out-of-pocket amount. Otherwise, the plan pays 70% of reasonable and customary expenses. Your 30% co-payment is the out-of-pocket expense. Please note that it does not include the deductible.

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Is massage therapy covered?

Massage therapy is not covered under the POS CIGNA Plan.

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Is chiropractic and Physical Theraphy benefits covered?

Effective January 1, 2010, the Health Fund implemented a major change in Chiropractic and Physical Therapy benefits.

In-Network Benefits: The benefits for in-network care were improved, with co-payments for visits to In-Network Chiropractic and Physical Therapy providers being reduced from $25 to $15.

Out-of-Network Benefits: The maximum allowable charges for out-of-network providers were reduced overall to approximately the same overall level as the reimbursements made to network providers. This means that, on average, they are significantly lower than they were before the change. The change in the maximum allowable charge for non-network providers will likely increase your out-of-pocket costs if you use a non-network provider.

Annual Cap on In and Out of Network Benefits: There is now a $4,000.00 annual cap that applies to in and out-of-network care combined for Chiropractic and Physical Therapy treatments in order to limit costs under the Plan.

Please visit our website, www.equityleague.org, under the Notices section of the Health Fund page for additional information. This update also applies to the Chiropractic Care on page 26 of the SPD.

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What is covered under Short-Term Rehabilitation Therapy, and what is the maximum visits each year?

You'll be allowed up to total of 60 visits a year between cardiac rehab, speech, and occupational therapy combined. If you go to an in-network provider, your co-pay visit is $25.00. If you happen to go to an out-of-network provider, then the payment for the visit is reimbursable at 70% of reasonable and customary after the $700.00 annual deductible has been met.

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Is acupuncture covered?

Acupuncture is covered with no specific limitation on the number of visits per calendar year; however, CIGNA will review the number of visits and only cover those that are medically necessary. If you go to an in-network provider, your co-pay visit is $25.00. If you happen to go to an out-of-network provider, then the payment for the visit is reimbursable at 70% of reasonable and customary after the $700.00 annual deductible has been met.

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Am I covered for infertility counseling, testing and lab services?

 CIGNA will provide coverage for infertility counseling, testing, and laboratory services. If you go to an in-network provider, your co-pay visit is $25.00. If you happen to go to an out-of-network provider, then the payment for the visit is reimbursable at 70% of reasonable and customary after the $350.00 annual deductible has been met.

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Are sterilization procedures covered?

Yes. CIGNA will cover in full the operating room fees and ancillary charges for sterilization procedures at a covered hospital. With CIGNA, if you see a provider that is in-network, the professional fees will be covered at 100%. If the provider is out-of-network from the CIGNA OAP network, the professional fees will be covered at 70% of the Reasonable and Customary charges after the $700.00 Deducible Amount has been met.

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Am I covered for the reversal of a sterilization procedure?

Reversal of sterilization procedures are not covered.

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How am I covered under the mental and nervous disorders benefit?

In-patient visits for mental and nervous disorders are covered to a maximum amount of visits of 30 per year. If you go to an in-network provider, your are covered at 100%. If you happen to go to an out-of-network provider, then the payment for the visit is reimbursable at 70% of reasonable and customary. Outpatient visits for mental and nervous disorders are covered to a maximum amount of visits of 45 per year .If you go to an in-network provider, your co-pay visit is $25.00. If you happen to go to an out-of-network provider, then the payment for the visit is reimbursable at 70% of reasonable and customary after the $700.00 annual deductible has been met. The services must be rendered by a licensed certified social worker, psychologist, or psychiatrist. In the State of California, a licensed family marriage therapist is a covered provider for psychotherapy only (marriage counseling is not covered).

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If I am pregnant and covered for benefits, are there any services covered for my newborn baby under my policy?

Any child that is born while you are insured for Medical Insurance will become insured for Insurance up to 31 days from the child's date of birth. All expenses will be paid for within 31 days for the newborn. If you want dependent coverage beyond 31 days for the child, then you must pay the required self-pay premium rate for dependent coverage. For example, if the child in born October 15, then all expenses will be paid for up until November 15. You then have the option to pay for dependent coverage as of November 1, or December 1. The Fund dependent premium is determined on a monthly basis.

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How am I covered for prescription drugs?

The Prescription Drug Plan is administered through CIGNA. Prescription Drugs are reimbursed in the following manner:

Deductible: Before the plan covers eligible prescription drug costs a $100.00 annual deductible will have to be satisfied. Please be aware that there will be a $200.00 maximum for a Family Deductible. At least one family member will have to meet the $100.00 deductible per calendar year.

At participating pharmacies: Present your CIGNA Identification Card.

Prescription Drug Benefits At A Glance
	At ENDSTATE Pharmacy	At a Non-Participating Pharmacy	Through the Tel-Drug Mail- Order Program
Annual Deductible- Must be satisfied regardless of where you obtain your prescription.
Individual	$100
Family	$200
Maximum Supply	30 days	30 days	90 days
Your Cost
Generic	Greater of $10 Copay or 20% of actual cost.	30% of actual cost.	Greater of $20 Copay or 20% of actual cost.
Preferred Brand-Name	Greater of $20 Copay or 25% of actual cost.	30% of actual cost.	Greater of $40 Copay or 25% of actual cost.
Non-Preferred Brand-Name	Greater of $25 Copay or 30% of actual cost.	30% of actual cost.	Greater of $50 Copay or 30% of actual cost.

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What will be my reimbursement if I go to a pharmacy that does not contract with CIGNA?

Your reimbursement when you fill a covered prescription drug at non-participating retail providers will be 70% of the discounted price that would have been paid to a participating pharmacy. Pay the full amount of the prescription and file a claim form. Mail your completed and signed claim form to CIGNA with an itemized receipt from the non-participating provider.

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Are prescription drugs rendered at the doctor's office covered?

Prescription drugs rendered at the doctor's office are covered in the same manner as prescription drugs that are obtained from a non-participating provider of the CIGNA Plan. Your reimbursement when you fill a covered prescription drug at non-participating providers will be 70% of the discounted price that would have been paid to a participating pharmacy. Mail your completed and signed claim form to Cigna with an itemized receipt from the doctor.

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Are durable medical supplies covered under the prescription plan or the major medical plan?

Durable Medical Supplies are covered under the major medical plan that is administered through the CIGNA Insurance Company. If in-network, they are covered at 100%. If out-of-network, they are reimbursed at 70% of reasonable and customary after the $700.00 annual deductible has been met. Certain supplies that pertain to your prescription may be covered under the prescription as well. Please contact the Fund Office to confirm which plan will cover these benefits.

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OAP [OPEN ACCESS PLUS PLAN] (Cigna administered Medical Benefit) TO USE INNETWORK PROVIDERS, use the CIGNA OAP (Open Access Plus) plan

Am I locked into using OAP providers exclusively?

No way. One of the best features of the OAP is that it's a choice you get to make each time you need medical care

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Are there surgeons in the OAP network?

Yes. In fact, there are over 450,000 specialists in the OAP network.

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If I want to see a OAP specialist, do I have to clear it with anyone first?

No. You can self-refer to any OAP physician, include specialists.

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Exactly how much is the OAP discount?

The OAP network is a national network, so the OAP allowance varies by region. But that should be a non-issue, since OAP benefits are paid at 100% of the allowance for that area, which means you'll never be on the hook for anything over the copay.

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I'm in an HMO, but now I am thinking of the OAP, and that Medical Plan is looking better and better. When do I have the opportunity to switch to take advantage of the OAP benefit?

You can switch your HMO to the OAP Medical Plan (or vice versa, for that matter) during any Yearly Open Enrollment, in which case your new coverage would take effect on January 1st. The Open Enrollment Period is the entire month of November each year.

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Will Major Medical cover more expenses under an OAP In-Network Provider Versus an Out-Of Network Provider?

No. The same expenses are covered whether or not you use an OAP In-network provider.

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When I take my daughter to her pediatrician for check-ups it's covered at 100% under Major Medical, so what's my incentive to switch to a OAP doctor?

First of all, it could turn out that the pediatrician is in the OAP network, in which case the only difference you'd see is that the savings. Here's why. The OAP reimburses at 100% of the OAP allowance, which is a discounted fee, whereas the non-OAP reimbursement is based on a percentage of the reasonable and customary charge. If the non-OAP doctor's charge is over the reasonable and customary amount, you'd be responsible for the difference.

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My partner's enrolled under my medical coverage. Does he get the OAP benefit, too?

Absolutely. All Plan participants have the option to add dependents to the plan in which they can take advantage of the OAP in-network benefits as well.

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Do I have to use a OAP provider to get benefits?

No. Benefits are still payable for covered expenses even when you use a non-OAP doctor. But remember, you'll have  to meet the $700 deductible before getting anything back on your non-OAP covered charges and you'll have to file a claim in order to be reimbursed.

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Does the OAP Network apply to the prescription drugs?

No. OAP benefits apply only to expenses covered under the Hospital Major Medical portion of the POS CIGNA Medical Plan. Prescription drugs, vision care, and dental expenses are not eligible for OAP discounts.

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Can I go to my own non-OAP provider for my routine medical care and to a OAP provider for, say, speciality care?

Absolutely. This is one of the great advantages of this plan.

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I'm on the road a lot. Let's say I get the flu and want to see a doctor. How do I find out who the local OAP providers are?

Easy. Either call CIGNA toll-free at (800) 244-6224 or log onto their website, http://cigna.com/. Please be aware that the toll-free number will be on the back of your Major Medical/Hospital identification card.

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Do OAP co-pays count toward meeting the $5,000 annual out-of-pocket coinsurance maximum?

No, nor do they count toward the $700 annual deductible.

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Can any provider belong to the OAP?

No. The providers in the CIGNA OAP Program have been very carefully screened. Each provider must meet strict standards of quality not just initially, but on an ongoing basis, as well.

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My wife and four kids are under the OAP plan. Does that mean each of us has to meet the $350 annual deductible?

There is a $700 maximum for the Family Deductible. At least one family member will have to meet the $350 deductible. The balance of the deductible can be a combined total. But remember, when you use OAP providers, there is no deductible, so you could save a considerable amount of money.

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Can retirees use the OAP?

Yes, as long as the POS CIGNA Plan, not Medicare, is the primary medical coverage. Basically, you need to be eligible by covered employment in which you MUST use the OAP plan as your Primary Coverage. Medicare will then become your Secondary Coverage.

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Are there OAP providers everywhere?

Easy access to OAP providers was a key criteria in choosing the CIGNA OAP plan. In fact, when the Trustees looked at where participants live, it turned out that over 99.7% of you live just a few minutes away from a OAP physician (within 3 miles if you live in an urban area, 12 miles if you live in the suburbs.) But remember, even if you're one of the few participants with no OAP network in your community, your eligible medical expenses still will be reimbursed exactly that way they are now. So while you may not have the same advantage as those who live in a "OAP community," you're not losing anything.

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If it turns out my doctor isn't in the OAP, can she get in?

If CIGNA is expanding its network in a particular area, they will accept physician nominations. For more details, have your doctor contact CIGNA's Provider Relations Department at (800) 244-6224.

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How will a OAP provider know I'm entitled to OAP benefits?

It will be on your ID card, so be sure to have your ID card with you when you go to the doctor's office. In fact, since your OAP provider must have a photocopy of your ID card on file, be sure to have the office assistant make a copy of it during your first visit. This way, there's a permanent record of your eligibility for OAP benefits on file.

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What if I don't get my new ID card by the start of my eligibility period?

You can contact CIGNA directly by calling toll-free at (800) 244-6224, or by contacting the Fund Office, (212) 869-9380 from the NYC area. If you're calling from outside the NYC area, call toll-free at (800) 344-5220

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Dental (coverage under the POS CIGNA and HMO plans)

When am I eligible for the Dental Care Plan?

Equity-League has a self-pay dental plan only for participants that have health coverage either under any HMO or the POS CIGNA Plans policy. The only participants members that are eligible for the dental plan are those that are covered for health benefits under the health plan.

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If I qualify for health coverage through covered employment, but do not make the $100 premium can I still elect to self-pay for dental coverage?

Yes, you may elect self-pay dental by electing not to pay the $100 premium for medical/vision coverage.

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What type of plan options are available under the CIGNA Dental Plan?

There will be two types of plans that will be available to participants that they can choose from. A PPO, and an Dental HMO(DHMO) are the types of plan options that will be in place for dental benefits. Participants that want to elect to self-pay into the dental plan can contact the Fund Office during the month of November of each year, or when they will be eligible for health benefits through covered employment. After a participant has elected his or her plan option, the participant will be billed by the Fund Office on a quarterly basis. A participant can also pay on a monthly basis as well. Please be aware that if participants elect not to continue to pay into the plan anymore, they CANNOT  participate into the plan until they re-qualify for health benefits at the start of a future eligibility period or during the Plan's Annual Open Enrollment period, November of each year.

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What is the quarterly cost that I am responsible for between the DHMO, and the PPO plans?

Here are the self-pay quarterly dental premiums as of 2012. Note that the premium rates may change each January 1.

	Quarterly Premium
If You Elect to Cover	CIGNA Dental PPO	CIGNA Dental Health (DHMO)
Yourself	$173.79	$84.48
Yourself + 1 dependent	$345.96	$136.62
Yourself + 2 or more dependents	$514.50	$239.58

For more information please contact the Fund Office at (212) 869-9380 or (800) 344-5220.

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Do I have a deductible under the CIGNA Dental Plan?

There are no deductibles under both the PPO and DHMO CIGNA Dental Plans.

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Vision (coverage under the Indemnity and HMO plans)

When am I eligible for the Vision Care Plan?

The Equity-League provides the Vision Care Benefits while you are eligible for health benefits under either the HMO Option or the Major Medical policy through the Indemnity Plan.

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How am I covered under the Davis Vision Plan (Vision Care)?

Benefits are available every 12 months for a routine eye examination (eye refraction and dilation) and every 24 months for a complete pair of eyeglasses or contact lenses (in lieu of eyeglasses). Davis Vision has a network of licensed providers. Reimbursement for services depends on whether you go in or outside the network of providers.

Participating/Network Provider Benefits:
o No co-payment is required toward your eye examination, including dilation as professionally indicated.
o No co-payment is required toward many spectacle lenses.
o No co-payment is required toward a any Fashion, Designer, or Premier level frame from Davis Vision's Frame Collection, covered in full. You will also have the option to select another frame outside of the Davis Vision Frame Collection within the network provider's office, where a $100.00 credit, plus 20% in excess of the $100.00 will be applied.
oA $25.00 co-payment is required toward standard, daily-wear, disposable, or planned replacement contact lenses. Your provider will give you specific information for the type of lenses you require. If you select lenses outside of the Davis Vision collection, a $115.00 credit, plus a 15% discount, in excess of this amount will be applied towards the purchase of this supply of contact lenses, evaluation, fitting, and follow-up care. The in-network credit allowance for non-formulary contact lenses will also apply at participating retail locations.

Out-of-network Benefits:
Services for out-of-network providers will be reimbursed up to the following schedule:
$30.00 for an eye examination
$25.00 per pair of single vision lenses
$35.00 per pair bifocal lenses
$45.00 per pair of trifocal lenses
$30.00 for a frame
$75.00 for contact lenses

Up to $225.00 for medically necessary contact lenses with prior approval.

Claims for non-participating providers should be sent to the Vision Care Processing Unit, PO Box 1525, Latham, NY 12110.

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Are there any optional frames, lens types, or coatings available?

Yes, you can pay low discounted fixed fees for the following optional items:

o $35.00 for standard ARC (anti-reflective coating). Premium ARC is $48.00 .
o $75.00 for polarized lenses.
o $55.00 for high-index (thinner and lighter) lenses.
o $65.00 for plastic photosensitive lenses.
o $30.00 for intermediate vision lenses.

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Am I still eligible for benefits if I go outside the Davis Vision Network?

You can go to any qualified vision care provider you choose. However, your reimbursement will be $30 towards an eye examination, $25 towards single vision lenses (per pair), $35 towards bifocal lenses (per pair), $45 towards trifocal lenses (per pair), $30 towards a frame (per pair), or $75 towards contact lenses in lieu of a complete pair of eyeglasses.

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Do I have a deductible under the Davis Vision Plan (Vision Care)?

There is no deductible under the Davis Vision Plan.

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How often am I eligible for Vision Care Eye Examinations?

A Vision Care eye examination is available once every 12 Months

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