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School District of Philadelphia Suburban Plan - Frequently Asked Questions (FAQs)

   ELIGIBILITY FOR BENEFITS

 

What benefits do I have?

The Philadelphia School District plan provides a comprehensive program of health benefits including hospital, medical, mental health and substance abuse and life insurance (including Accidental Death & Dismemberment).

You have prescription drug, dental, and vision coverage through a separate plan from the Local 1201 Health and Welfare Fund.

 

How can I get a new or another insurance ID card?

If you have not received an ID card for any of your benefits or need an additional ID card for a dependent please call Member Services at 800-551-3225.

 

How do I know if a health service is covered?

You should review your Summary Plan Description (SPD) for detailed coverage of all your benefits. If you have additional questions contact Member Services at 800-551-3225.

 

Are my dependent(s) eligible?

Yes, your collective bargaining or participation agreement provides for family coverage. In general, your covered dependent(s) include your spouse and your children until they reach 26 years of age (refer to your (SPD) for more information).

 

What do I have to do to cover my dependent?

  • Fill out and return the appropriate form.
  • Provide documentation that proves that individual you want to enroll is your dependent. For example, you must provide a marriage certificate to cover your spouse or a birth certificate for a dependent child.

Call Member Services at 800-551-3225 for more information.

Click here to access the Dependent Enrollment form

 

What happens if I have a change in my life (like marriage, birth of a child or divorce)?

You must:

  • Notify the Fund thirty (30) days of the date of the event (such as marriage or birth).
  • Fill out and return the appropriate form.
  • Provide documentation proving the relationship.

If you notify the Fund within thirty (30) days, your dependent will be covered from the date of the event (birth, adoption, marriage). If you do not notify the Fund within thirty (30) days of the event, your spouse/child will only be covered prospectively from the date you notify the Fund.

 

Do I need to enroll to be covered for benefits?

No, you are automatically enrolled in benefits but you will need to enroll your eligible dependents.


   MEDICAL & HOSPITAL

 

Which doctors can I see?

You have coverage for doctors both in-network and out-of-network. Using out-of-network doctors can be very expensive for you and is not recommended. You have access to a large network of in-network doctors with minimal co-pay costs to you through the Independence Blue Cross’s (IBC) Keystone Direct Point-of-Service ("POS") network*. To find in-network doctors please go to https://provdir.ibx.com/ or call Member Services at 800-551-3225.

*If you live outside the IBC service area which includes the Philadelphia metropolitan area and parts of New Jersey and Delaware, you have the IBC Personal Choice PPO network and you can find a full listing of providers at https://provdir.ibx.com/.

 

Do I need to select a Primary Care Physician (PCP)?

Yes. Each covered individual must select a PCP from the IBC POS network and advise IBC. Call IBC Customer Service at 800-275-2583 to select your PCP. This selection will be printed on your IBC identification card. Your PCP must make referrals for you for 5 services- X-Rays, physical therapy, occupational therapy, podiatry and laboratory services.

 

Do I need a referral from my Primary Care Physician (PCP) for other specialist visits?

No, you do not need a referral and can see all other participating specialists directly. Just make sure they are a participating IBC Keystone POS specialist to be covered with only a co-payment.

 

What does it cost me to see a doctor?

When you see an in-network doctor you may have a co-pay. The following chart clearly describes your co-pay based on the doctor or provider you choose.

  IBC Participating POS Providers
Doctor Office Visits $15 co-payment/visit

 

If you see an out-of-network doctor, you will pay more. You will pay the $250 annual deductible, 30% of the allowed amount and all charges above the allowed amount. The allowed amount is usually significantly less than what an out-of-network doctor charges so the costs to you could be significant.

 

If I am away from home, am I covered when I see a doctor?

Yes, you are covered for all urgent or emergent care. Just make sure you see a doctor that is a participating provider in a local BlueCross BlueShield network to get the highest level of coverage.

 

What happens if I need care while I am traveling abroad?

You are only covered for emergencies when traveling outside the country. You will need to submit a claim for reimbursement when you return to the U.S..

 

What do I pay when I use the Emergency Room?

When you use the Emergency Room you will pay a $100 co-pay.

 

What do I pay if am admitted to the hospital for an overnight or longer stay?

If you are admitted to an in-network hospital you will pay nothing ($0) for the hospital admission. There is no additional cost to you for in-network services, but if you are seen by out-of-network doctors (including surgeons and anesthesiologists) you may receive additional bills for those doctors. We advise you to only use in-network doctors while at the hospital whenever possible. Please call Member Services at 800-551-3225 if you receive bills for out-of-network providers at an in-network hospital.

 

Besides in-network doctor office visit co-pays, what other co-pays will I have when receiving care from an in-network provider?

If you only see doctors and providers that are in-network and use facilities that are in-network the following chart details all co-pays that you may have to pay. If you stay in-network you do not have a deductible or co-insurance payments to worry about.

Hospital & Facility Visits $0
Hospital emergency room $100 per visit

 

 

Is prior authorization required to receive services? Do I need to get permission before I can use some services?

Yes, prior authorization is required for the following services:

  • High-tech Imaging (CAT/PET scans, MRIs/MRAs and Nuclear Medicine tests)
  • Other Imaging Services (bone density testing and echo stress tests)
  • Hospital and in-patient surgery
  • In-patient and intensive out-patient Mental/Behavioral Health
  • In-patient and intensive out-patient Substance Abuse Disorder
  • Rehabilitation Services
  • Radiation Therapy
  • Skilled Nursing Care
  • Hospice Service (in-patient only)
  • Durable Medical Equipment
  • Physical and Occupational Therapy
  • Air ambulance (non-emergency)
  • Ambulatory surgery (reconstructive and optical procedures)

When you use participating providers, the provider is required to obtain the prior authorization for you.


   MENTAL HEALTH OR SUBSTANCE ABUSE

 

How can I find a mental health or substance abuse provider that is in-network?

To find in-network doctors please go to https://provdir.ibx.com/ or call Independence Blue Cross at 800-275-2583.

 

What do I pay when I see an in-network mental health or substance abuse provider?

Benefit In-Network
In-patient mental health or substance abuse $0 co-pay
Office visits $15 Co-pay
Outpatient hospital facility $0 co-pay

 

 

What if I or my family needs immediate mental health or substance abuse assistance?

Call IBC’s Magellan Behavioral Health 24/7 at 800-688-1911.


   PRESCRIPTION DRUG BENEFIT

 
 

You have prescription drug coverage through a separate plan from the Local 1201 Health and Welfare Fund.


   DENTAL BENEFIT

 
 

Your dental coverage is provided through a separate plan with your union, Local 1201.


   VISION BENEFIT

 
 

Your vision coverage is provided through a separate plan with your union, Local 1201.


   LIFE INSURANCE BENEFIT

 

What is my life insurance benefit and how does my beneficiary claim this benefit?

You have a $25,000 life insurance benefit with MetLife. You beneficiary should contact Member Services at 800-551-3225 when filing a claim.


   GENERAL QUESTIONS

 

Do I have to file claims?

If you use a participating provider, you do not have to file any claims; the provider will do it for you.

 

What if I have other health insurance?

If you, or your dependent(s), have other insurance, the Plan and your other plan will coordinate benefit payments. One plan will be Primary and the other Secondary. Generally, the Plan that covers you, or your dependent, through work is the Primary Plan; for example, if your spouse has coverage at work, that plan will be Primary for your spouse. The Primary Plan will pay first and the Secondary Plan may reimburse you for the remaining expenses up to the allowed amount. This process is known as Coordination of Benefits or COB (refer to your SPD for more information).

 

If I stop working, how long can I stay on the health coverage?

Your coverage will end on the last day of the second pay period in which no hours are reported. Prior to the expiration of your coverage, you will be offered under the Consolidated Omnibus Budget Reconciliation Act of 1986 (“COBRA”) the opportunity to purchase vision coverage for up to seventeen (17) months from your eligibility end date. COBRA coverage is very expensive because you pay the entire premium. Before you elect COBRA, you should go to www.Healthcare.gov to learn what options may be available to you in the Healthcare Marketplace.

 

What happens to my health coverage if I become disabled?

If you are eligible, the Fund will pay continued health coverage (Fund-paid Health Extension). This coverage counts toward the time you are eligible for COBRA. To be eligible, you must:

  • Have become disabled while working in covered employment.
  • Be unable to work.
  • Be receiving (or be approved to receive) one of the following benefits:
    • Short-term Disability ("STD").
    • Worker’s Compensation.

If you are covered by the Philadelphia School District plan, your coverage may be extended for up to twelve (12) months for Short-term Disability and up to thirty (30) months for Workers’ Compensation.

 

What happens to my family’s coverage if I die?

If your family is enrolled/covered on the date of your death, their coverage will continue at no cost for thirty (30) days. Prior to the expiration of the thirty (30) days, your family will be offered the opportunity to continue coverage under COBRA for 35 more months by paying a monthly premium. COBRA coverage is very expensive because you pay the entire premium. Before you elect COBRA, you should go to www.Healthcare.gov to learn what options may be available to you in the Healthcare Marketplace.

 

Who do I call if I have questions?

Call Member Services at 800-551-3225 Monday through Friday between the hours of 8:30am to 5:00pm. Or visit the Welcome Center at 25 West 18th Street, New York, NY 10011, Monday through Friday between the hours of 8:30am - 6:00pm.