What if I go to the emergency room and the doctor assigned to me is not a participating provider?

In the case of a legitimate emergency, the claim will be paid as participating to the Table of Allowances. However, emergency rooms are often used as a convenience, either because it is after the doctor’s normal business hours, or because the member does not wish to wait for an opening in the doctor’s schedule. If your visit is not determined to be an emergency, the claim will be processed according to the Nonparticipating Provider Option of your plan. (If your plan does not have a Nonparticipating Provider Option, benefits will be denied.) Studies show that 75 percent of all emergency room patients could have waited to see their own physicians. Emergency rooms are stocked with extra equipment for real emergencies, resulting in fees that are three times higher than the average office visit. Emergency room visits should be reserved for true emergencies.

I paid my emergency room copayment; why am I receiving additional bills from the hospital and the physician?

Your emergency room copayment may not cover all of the services you received during your visit to the emergency room. If your Summary of Benefits chart indicates “Outpatient, including ER” after some benefits, that means you are responsible for the applicable coinsurance or copayment for those services, even if you received them as part of an ER visit. In addition, if you visited a nonparticipating facility, even in an emergency, you are responsible for amounts exceeding the Table of Allowance.

What is the Table of Allowances?

The Table of Allowances is the schedule for payment of eligible charges. All benefits are subject to the Table of Allowances. For example, if a provider charges $125 for a procedure for which the Table of Allowances permits a $100 payment, Educators will pay the specified percentage of $100—not $125. Participating providers have agreed to write off any amounts in excess of the Table of Allowances. Nonparticipating providers are under no such obligation. That means that even if Educators pays for services from a nonparticipating provider according to the Participating Provider Option of your plan (because of an emergency situation), you may still be responsible for any amount exceeding the Table of Allowances.

Will my plan pay for a routine or screening colonoscopy?

Most doctors recommend you receive your first screening colonoscopy at age 50, unless you are experiencing symptoms or you have a family history of colon cancer. Most Educators plans cover a screening colonoscopy up to once a year according to the outpatient medical/surgical benefits of the plan. Depending on your plan design, you may have a deductible and/or a coinsurance.

If you have a family history of colon cancer, and your plan has a family history benefit, your colonoscopy may qualify as a Family History Exam (which typically requires less out-of-pocket expense than the standard outpatient medical/surgical benefit). In order to receive this benefit, you must use a participating provider and facility.If you have a medical condition or are experiencing symptoms, medically-necessary colonoscopies will be covered according to the appropriate benefits of your plan (usually outpatient medical/surgical).

Call customer service at 800-662-5851 for the details of your plan.

How can I determine what services are subject to the deductible?

Look at your Summary of Benefits chart. Any copayment or coinsurance that is preceded by a ♦ is subject to a first-dollar deductible. The deductible is the amount you must pay for eligible expenses out of your own money before any benefits will be paid by your plan. Most plans include separate deductibles for Participating Provider Option benefits and Nonparticipating Provider Option benefits.

Are coinsurance maximum and out-of-pocket expenses the same thing?

No. The coinsurance maximum is designed to insure against financial hardship caused by unexpected expenses from catastrophic illness. When you have satisfied any applicable deductible and paid eligible expenses up to the coinsurance maximum, the plan will pay remaining eligible expenses at 100 percent of the Table of Allowances. However, this does not mean that you will not have any additional out-of-pocket medical expenses. If you receive any service or treatment specified as a limited benefit, the plan will pay for services only up to the specified amounts. Any expense incurred for amounts in excess of the specified percentage, day, or dollar limits, and expenses you pay for not following preauthorization procedures, will not be reimbursed by the plan and will not accumulate toward the annual coinsurance maximum. In addition, it is important to note that the Participating Provider and Non-participating Provider Options each have a separate coinsurance maximum.

When will I receive my Educators ID card?

You should receive your card within two weeks after Educators receives your enrollment application. You will receive two ID cards attached to the bottom of a welcome letter. Educators will never send you junk mail, so please carefully review anything you receive from Educators. If you require medical services or prescriptions after your effective date, but before you receive your ID card, contact Educators’ enrollment department at 800-662-5851.

What services are available to me online?

Educators website www.educatorsmutual.com offers a number of benefits for its members:

• Participating provider listing
• Electronic Explanations of Benefits (claims statements)
• Downloadable forms
• Prescription drug benefit management
• Flexible Spending Account (FSA) management
• Wellness Web
• Discount services and supplies
• BeneFacts newsletters
• Healthcare and benefit tips

I have coverage under more than one plan; how do I file claims with the secondary carrier?

Most providers will file the claims with both insurance companies if you give them all of the information. When Educators is the secondary carrier, we require an explanation of benefits from the primary carrier, as well as an itemized statement from the provider, including the medical diagnosis and procedure codes.

If I have two insurance plans, could I still have out-of-pocket expenses?

You may still need to pay some expenses out-of-pocket. Educators will never pay more than we would have paid if we were the primary carrier. The plan deductibles, copayments, and Table of Allowances still apply. For example, if the claim is for $100, and the primary carrier paid $80 (leaving a balance of $20), and your Educators plan has a $100 deductible, the $20 balance would be applied toward your deductible, but Educators would not pay anything toward that claim. However, if your Educators plan would have paid $80 (with no deductible) as the primary carrier, Educators would pay the $20 balance.

How long will my children be covered on my plan?

Most groups cover dependent children through the month of their 26th birthday or until they are married. Some self-insured plans cover dependent children through the month of their 23rd birthday. Children may not have to be covered on your tax return to qualify for coverage on your medical plan. Call Educators enrollment department at 800-662-5851 for the requirements of your plan.

What immunizations are covered by my plan?

Plans vary on which immunizations are covered. Please check your member handbook or call Educators customer service department at 800-662-5851 for the details of your plan. In order to receive coverage for eligible immunizations, you will need to use a participating provider.

If my doctor practices at several locations, can I assume he is a participating provider no matter which location I visit?

No, the same physician can be a participating provider at one location and a nonparticipating provider at another. Always verify that the provider and the location are participating on your plan by visiting www.educatorsmutual.com or calling customer service at 800-662-5851.

What is a preexisting condition?

A preexisting condition is a condition for which medical advice, diagnosis, care, or treatment was recommended or received within the plan’s designated period (usually six months) prior to the enrollment date. The preexisting condition limitation period refers to the amount of time a member must wait after enrolling in a new plan before being covered for most preexisting conditions.

I was covered under another insurance plan before I switched to Educators; will the preexisting condition limitation apply to me?

The preexisting condition limitation period may be reduced or waived if you have had continuous coverage by another carrier, and you have documentation from that carrier. You can get a Certificate of Creditable Coverage from your prior health plan or insurance carrier. Give that Certificate to Educators as quickly as possible to expedite receiving credit for previous coverage. You also have the right to demonstrate creditable coverage through documentation other than a Certificate of Creditable Coverage; however, a Certificate of Creditable Coverage will provide Educators with the most complete information and will expedite the processing of your claims. If it has been 63 days or more since you last had insurance coverage, your preexisting condition limitation period will not be reduced.