General Plan Information
Termination of Employment and COBRA
Dependent Enrollment and Eligibility
Health Insurance Information
Dental Plan Information
Vision Benefit Information
Claim Submissions, Appeals, and Denials
General Plan Information
1. What benefits do I receive through the Voluntary Hospitals House Staff Benefits Plan?
You are entitled to health insurance through Empire BlueCross/BlueShield, dental insurance through Guardian, and prescription coverage through Express Scripts. You will receive three separate insurance cards from each of these providers. Your optical benefit is provided through VHHSBP – click here for information on how to use your optical benefit.
In addition, you are entitled to short and long-term disability, life insurance, hearing aid benefit, and legal services. You will be automatically enrolled in these benefits when you complete your enrollment form. For details on each benefit, refer to the summary plan description.
2. I recently enrolled myself and/or dependents in the benefits plan – how long will it take to receive insurance cards?
If you enrolled during orientation (June), it can take several weeks before your information is registered due to the large volume of enrollments we receive during this time period. You can expect cards sometime toward the end of July or early August. However, all coverage will be effective from your start date. Enrollments during all other times of the year typically take 2-3 weeks to process. If you have an emergency and do not have an insurance card yet, you should contact the benefits office immediately.
To request a new health insurance card, contact Empire at 1-800-553-9603. Our group number is 720070.
For prescription cards, contact Express Scripts at 1-866-439-3658. Be sure to refer to our group number when you call: K4DA.
For optical, there are NO insurance cards – click here for more information on how to use your optical benefit.
4. I contacted my insurance provider for information and they said I wasn’t enrolled yet, even though I completed my enrollment form. Why not?
It takes at least 2-3 weeks from the time you submit your enrollment form for your information to be processed by our office, and for our insurance providers to receive this information. If you enrolled more than 2-3 weeks ago, and are still not active, please contact the benefits office immediately. Missing social security numbers, date of birth, gender, or missing address can delay your enrollment and prevent your coverage from being active.
5. What is open enrollment and when does it occur?
Open enrollment is the period where you can change your dental plan, or add dependents to your plan if you did not enroll them previously. See adding dependents for more information. If you opted out of benefits previously, you may also opt back in during this time. Open enrollment occurs every January and July and forms must be received by January 31 or July 31 of the open enrollment period.
6. I recently moved – how can I update my address?
To notify the plan of an address change, contact the benefits office at 212-356-8180. You may also email, fax, or mail in your address change request. Once you provide us your address, we will send this information automatically to our insurance providers (Empire, Guardian, Express Scripts).
8. How much do I pay for benefits for myself and dependents?
Benefits are provided at NO COST to you or your eligible dependents (spouse and children). However, for domestic partners, you will incur a tax liability on the value of the benefits at the end of the year. See domestic partners for more information.
9. Union dues are taken out of my paycheck bi-weekly. Is this for my health insurance premium?
No, members do not pay any premiums for benefits. The union has negotiated for your hospital to pay the full premium. Union dues go directly to the union to support the work involved in organizing, contract negotiations, and other organizational costs. For more information on dues, you should contact CIR directly at 212-356-8100.
10. I already have insurance through my spouse. Can I opt-out of the benefits plan?
You may opt-out of the benefits plan at any time, provided you complete an opt-out form and provide proof of alternate insurance. However, keep in mind that you do not pay anything for your benefits, and by opting out, you and your dependents will be removed from all parts of the benefits plan, including health insurance, prescription, dental, optical, disability, life insurance, and legal services. If you would like to opt back in at a later date, you must wait until open enrollment to do so or loss of your alternate insurance.
Termination of Employment and COBRA
11. I am graduating/terminating from my residency program soon – when will my benefits end?
If your termination date is the final day of the month (i.e. June 30) your benefits will end on that day. If you terminate any other day during the month (i.e. July 10), your benefits will continue through to the end of the month (July 31). Once we receive a termination date from your hospital, we will automatically mail you a COBRA letter, which will provide information on how to continue your health coverage. See What is COBRA? for more information.
12. What is COBRA?
COBRA is a Federal Act that allows employees and their eligible dependents to temporarily continue their health coverage due to reduction of work hours or loss of employment. You may extend your coverage for a maximum of 18 months and you must pay the monthly premium in order to remain active.
13. What benefits are covered under COBRA?
Your health insurance, prescription coverage, dental insurance, and optical benefits will all continue under COBRA. Legal services, disability, and life insurance will terminate at the end of employment. However, you will have the right to convert your life insurance and disability coverage to an individual policy, and will receive information about your conversion rights in your COBRA letter.
14. How long will my COBRA coverage last?
You may extend your coverage for a maximum of 18 months. If an additional qualifying event occurs while on COBRA (death of employee, divorce, or child ages out of plan), the spouse and/or children may extend their COBRA coverage for an additional 18 months, for a total of 36 months.
15. Why haven’t I received my COBRA letter yet when I terminated residency already?
Contact the benefits office at 212-356-8180 and make sure we have your termination date on file. We rely on your employer to notify us of your residency termination date, and occasionally, there are delays in receiving this information. In addition, make sure we have your most current address on file. Once we have this information, we can generate a COBRA letter for you.
16. How much is the COBRA premium?
Premiums range from $300-400 per month for an individual plan, and $700-800 per month for a family plan. However, rates fluctuate each year, and you should contact the benefits office for the most current rates.
17. How long do I have to elect COBRA?
You must send in your COBRA election form within 60 days from the date you terminated employment, or the day you receive your COBRA letter, whichever is later. Failure to elect COBRA within 60 days will result in the denial of continuation coverage.
18. Once I elect COBRA, when will my benefits be reinstated?
Your benefits will be reinstated the day immediately following your termination date, regardless of when you turn in your election form. For example, if you terminated on June 30, and send your election form on August 15, your COBRA benefits will become effective from July 1. In addition, you will be required to pay the July premium, regardless of whether you used your benefits in July.
19. I elected COBRA, but haven’t received new insurance cards yet. Why not?
COBRA is a continuation of the same benefits you had while you were employed, and you may continue to use the same insurance cards. Your cards will only change if you changed your dental plan when you converted to COBRA, or if you moved out-of-state, and now require an Empire PPO plan. If you need new cards, you should contact the numbers listed here.
20. How can I pay for COBRA?
The plan currently accepts check or money order payment, or credit card payments using Visa or MasterCard only. To elect credit card, you must fill out the electronic credit card authorization form.
21. When is my COBRA premium due?
Premiums are due on the first of every month if you pay by check or money order. If you fail to submit your premium by the first, you have 30 days to remit payment before your coverage is terminated. If you are paying by credit card, we will automatically charge your premium on the 28th of the month for the upcoming month.
22. Why haven’t I received a statement or bill for my COBRA?
The benefits office will not send you a monthly statement for your COBRA premiums. You are responsible for making your payment on time each month if you are paying by check or money order. If you elected credit card payment, the plan will automatically charge your premium on the 28th of the month for the upcoming month that a premium is due.
23. I have a new insurance plan. How can I terminate my COBRA benefits?
You should contact the plan in writing to notify us you would like to cease your COBRA benefits. If you are paying by credit card, we must receive your letter at least 10 days prior to the end of the month, so we may terminate the automatic billing on your card. You can download and complete a sample termination letter here.
Dependent Enrollment and Eligibility
24. I just had a newborn and/or got married – how can I add my dependent to the benefits plan?
To add a dependent to the benefits plan, contact the benefits office at (212) 356-8180 and request a benefits change form, or download one on our website. If you are adding a newborn, you must provide a copy of the hospital discharge papers OR birth certificate. If you are adding a spouse, attach a copy of your marriage certificate. Mail or fax all enrollment materials to the benefits office within 30 days from qualifying event (marriage or birth).
25. How much time do I have to add my spouse/child to the benefits plan?
All additions to the plan must be made within 30 days of the qualifying event (birth or marriage). If you fail to notify the Plan within 30 days, you will need to wait until the next open enrollment period (January and July) to add your dependent.
26. My spouse lost his/her insurance from their previous employer. How can I add them to my benefits plan?
Contact the benefits office at (212) 356-8180 to request a benefits change form, or download one on our website. You must notify the plan within 30 days of the loss of coverage, and provide a certificate of coverage from their previous employer showing when their coverage ended. In addition, you must also provide a copy of your marriage certificate. If you fail to notify the plan within 30 days, you will need to wait until the next open enrollment period (January and July) to add your dependent.
27. I just added my newborn to the benefits plan today, and we have a doctor’s appointment tomorrow. Can I still go?
Yes. Newborns are covered as a temporary member under the plan for the first 30 days. Simply provide the mother’s insurance card, and your provider will send the information to Empire to be processed when the child’s enrollment is complete. Allow at least 2-3 weeks for the receipt of your newborn’s insurance card.
28. Is it possible to add my mother or father to the benefits plan?
No. Eligible dependents include your legal spouse, dependent children/step-children, or your registered domestic partner. Parents, grandparents, or other relatives are not eligible for benefits.
29. How can I enroll my domestic partner in the benefits plan?
To enroll a domestic partner, download an application here. You must provide at least two documents as proof of partnership and have your form notarized. Refer to the application for a list of acceptable documents. In addition, you will be taxed on the value of the benefits at the end of the year, which will be added to your W-2 as income. Refer to the application for more details or contact the benefits office.
30. How long will my child be covered on the benefits plan?
Children are eligible for health insurance until the age of 26 (end of calendar year). For dental and optical benefits, children are covered until the age of 19, or until the age of 23, provided they are a full-time student at a post-secondary institution. You must provide proof of full-time student enrollment each semester they are enrolled.
31. What benefits are my dependents eligible for?
Spouse and children are eligible for all the benefits including health insurance, prescription, dental, optical, hearing aid, and legal services. The only benefits that are MEMBER ONLY are disability. Life insurance is for member and spouse only. Refer to the summary plan description for details on each benefit.
32. How can I remove my spouse or child from my insurance policy?
To remove any dependent, you must complete an opt-out form. In addition, you must provide a copy of their alternate insurance by submitting a certificate of coverage or copy of their ID card from their health provider. When you opt-out a dependent, you will remove them from ALL parts of the benefits plan, including health insurance, dental, optical, and legal services.
Health Insurance Information
33. What kind of health insurance plan do I have?
The health insurance is provided through Empire BlueCross/BlueShield, and is a DirectShare POS (Point-of-Service) plan. With your DirectShare POS plan, you have the option to go in-network or out-of-network, although costs will be always be lower when you use in-network providers. If you reside outside of the tri-state area (NY, NJ, CT) you will be transferred to the Empire PPO plan. Coverage is similar to that of the POS plan, and you will have a greater network of providers to choose from.
For complete details on coverage, visit the VHHSBP summary page.
34. What is the difference between using an in-network or out-of-network provider?
When you choose an in-network provider, your health care costs will be lower, and you will only be responsible for your co-pay. If you go out-of-network, you will be responsible for meeting your yearly deductible, in addition to paying 20% of reasonable charges (50% for behavioral health). Also, when you go out-of-network, you are responsible for precertifying certain services, whereas, when you go in-network, the provider will precertify these services for you.
35. How can I locate an in-network provider?
Visit www.empireblue.com and click on “Find a Doctor”. Be sure to select the Empire DirectShare POS plan from the drop-down menu.
36. What is a co-payment?
A co-payment is the amount that a patient is responsible for at the time they visit a physician or hospital, or have a prescription filled. The patient is responsible for this fee up-front, while the insurance provider covers the remaining cost of the medical service or prescription. Under Empire, you co-payment is $20 for office visits and $25 for behavioral health visits. For emergency room visits, your co-pay is $35, but is waived if you are admitted.
37. What is a deductible?
A deductible is the out-of-pocket amount a plan participant must pay before the health insurance covers any medical expenses. Under Empire, you will only pay a deductible if you go out-of-network, and deductible amounts are $100/ individual or $200/family. In addition, after you meet your yearly deductible, you are also responsible for paying 20% of reasonable service charges, while Empire will pay 80% of reasonable charges.
38. What services need to be precertified and how?
Click here for the list of services that need to be precertified. When you go in-network, your provider will contact Empire to precertify these services for you. When you go out-of-network, it is YOUR responsibility to precertify these services. Precertification is necessary to ensure you receive the best quality care for the maximum length of time with the maximum coverage. To precertify services, you should contact Empire’s Medical Management Program at 1-800-845-4742.
39. I have a question about a specific health service or claim – who should I contact?
Questions regarding specific services or health claims should be made directly to Empire. You can contact a customer service representative at 1-800-553-9603. Click here for a complete list of customer service numbers for medical management, behavioral health, and insurance fraud.
40. Is my prescription benefit covered under my Empire plan?
No, your prescription coverage is provided through Express Scripts, and you will receive a separate card. Click here for more information on prescription benefits.
41. I have a doctor’s appointment today but don’t have my insurance card yet. Is there a temporary card I can download?
Yes. Visit www.empireblue.com and select Register Now. You will be prompted to enter the member’s name, date of birth, and member ID. The member ID is the member’s social security number. Once you enter this information, you will need to create a username and password. After you log-in, you will be able to print a temporary ID card that you can use at the provider’s office.
Dental Plan Information
42. What is my dental insurance?
Your dental insurance is provided through Guardian (Group G-417733). The plan offers two options, a Managed DentalGuard (MDG) and DentalGuard Preferred (DGP) plan. Both plans are tailored to provide quality, comprehensive dental care. MDG provides low, fixed rate dental costs but requires you to choose from a network of participating providers. DGP provides greater flexibility of dentists, but typically has higher out-of-pocket costs. See below for more information on selecting dentists, changing plans, and differences between plans.
43. I don’t have a dentist yet but want to elect MDG– do I need to fill in a MDG provider number on my enrollment form?
No, you do not need to select a dentist at time of enrollment. However, you will be assigned a provider closest to your home zip code. If you wish to change your dental provider at a later date, you can contact Guardian at 1-888-600-1600. If your home zip code is out of the tri-state area, you will be defaulted to the DGP plan, and will need to switch back to MDG during open enrollment.
44. I have the Managed Dental Guard plan – how can I change my dentist?
To change your primary care dentist, contact Guardian at 1-888-600-1600. You can change your dentist once per month, and the change will register the first of the following month. To search for providers in your local area, search the provider directory at www.guardianlife.com and select the MDG/Pre-paid plan from the drop down menu.
45. I currently have the Managed Dental Guard plan, and want to change to Dental Guard Preferred. When can I change?
Open enrollment is every January and July. Dental change requests must be submitted by January 31 or July 31 to take effect during the open enrollment period. We automatically send dental enrollment forms to members the month prior to the open enrollment period. If you did not receive a form, or misplaced it, you can download a form here.
46. What is the difference between the Managed DentalGuard (MDG) and the DentalGuard Preferred (DGP) Plan?
The MDG plan is designed to provide quality dental care, while controlling the cost of such care. To do so, you must select a dentist in the Managed DentalGuard network. For most basic services there are no co-pays, and for advanced services, you will pay a co-payment to the provider. Refer to the fee schedule for a list of covered services and co-pay amounts. There are no annual maximums or limits on the services one can receive in a given plan year. In addition, orthodontic work is only covered under the MDG plan, and not under DGP.
The DGP plan provides the flexibility to choose any dentist you want. However, if you go in-network (to a dentist that accepts DGP), Guardian will cover up to $2000 of reasonable charges per plan year. If you go out-of-network, Guardian will cover up to $1000 of reasonable charges per plan year. Reasonable charges are determined by Guardian, and does not mean you will be reimbursed 100% of the service cost, even if you have not met your annual maximum. Refer to the covered charges chart for percentages, or contact Guardian for additional information at 1-888-600-1600. If you or your dependents reside outside of the tri-state area (NY, NJ, CT), you must elect the DGP plan if you wish to receive services in your home state.
47. What is the vision benefit and how do I use it?
Our vision plan is through Davis Vision. Log in to the open enrollment section at www.davisvision.com and enter client code 2189 to locate a provider near you. Refer to the Optical Benefit Summary for complete details on coverage.
48. I could not locate an optical provider in my area – can I still use the benefit out-of-network?
Yes. You can use the benefit out-of-network, but you will need to download a Davis Vision claim form and submit it directly to Davis Vision for reimbursement. Claim forms are available on our benefits website or at www.davisvision.com. Keep in mind the allowance for out-of-network services is $40 toward an eye exam and $60 toward materials (contacts or glasses).
49. Do I need an insurance card to go to an optical provider?
No. If you do not have your Davis Vision ID card when you visit an in-network provider, the provider can look you up by your first and last name, or member ID number.
50. Can I purchase glasses and contacts in the same plan year?
No. When you go in-network, you are only allowed to purchase one or the other in any given plan year. If you require both glasses and contacts, Davis Vision offers a mail order contact lens program, Lens123, that offers competitive pricing for all your contact lens needs after you have used your benefit for the plan year. Visit www.davisvision.com for more information on their Lens123 program.
51. What happens if I go in-network, but the optical provider cannot find me in the database?
Contact the benefits office to confirm you are enrolled and eligible for vision services. Missing social security numbers, date of birth, or failure to complete an enrollment form can prevent your benefits from being active.
If you choose to use mail order, you will receive a 90 supply of medication, and your copay will be as follows:
$10 for generic
$30 for brand
$60 for non-formulary
If your pharmacy does not participate in the Express Scripts network, you must pay out-of-pocket, and then file a claim with Express Scripts to be reimbursed.
53. How can I elect to receive my prescriptions via mail order?
For mail order prescriptions, you should visit www.express-scripts.com and register. You will be able to download a mail order prescription form and mail it to Express Scripts.
54. I didn’t have my prescription card at the time of purchase, and paid out-of-pocket. How can I get reimbursed?
Download an Express Scripts claim form that is available on the VHHSBP home page. Attach your prescription receipts and mail your claim directly to Express Scripts, and they will reimburse you.
55. I don’t have my prescription card yet. Is there a temporary card I can bring to the pharmacy?
Yes, you can download a temporary card here, and present this at your pharmacy. Alternately, you can pay out-of-pocket, and download an Express Scripts claim form to get reimbursed.
Claim Submissions, Appeals, and Denials
56. How do I submit a claim?
First, download a claim form from the VHHSBP home page. Please read the claim submission guidelines carefully, and make sure you submit all requested documentation, including receipts, prescription readings, or other applicable items. After you have attached the appropriate documentation, submit your claim to the provider at the address located on the claim form. Remember to MAKE A COPY of your claim for your records.
58. My claim was denied and I would like to appeal the decision. What should I do?
First, you should contact the Benefits Office and make sure you understand the reason for the denial. If further documentation is missing, you can resubmit your claim to the Plan without going through an appeals process. If you are appealing on the grounds of denial due to late filing (past one year), or for denial for services that are not covered under the plan, you must write an appeal letter to the Board of Trustees. All appeals should be addressed: Attention Michelle Cordova. Mail or fax your letter to the benefits office, and include a copy of your Explanation of Benefits illustrating the denial.
59. How long do claims take to process, and how will I be notified?
Claims take 4-6 weeks to process, after which time you will receive a check mailed to your home address. If your claim is denied, you will receive an Explanation of Benefits detailing the reason(s) for the claim denial.
61. My claim was denied – why?
Claims can be denied for various reasons, including insufficient documentation, a missing prescription reading, or late submissions, to name a few. You should consult the Explanation of Benefits (EOB) that was mailed to you, and refer to the section titled “Remarks”, located in the middle of the page to find out why your claim was denied. If you still do not understand the reason for denial, you may contact the benefits office for further details.
60. My claim was originally denied due to missing documentation, and I would like to resubmit. Do I need to resubmit the entire claim again?
No. Simply submit the Explanation of Benefits (EOB) that was mailed to you, and attach the missing documentation. If you no longer have the EOB, than you should submit a new claim form and attach it to the additional documentation. Include a note on your new form explaining that this is a resubmission, so that we may locate your original claim. Please do not send any stray receipts, invoices, prescription readings, or other materials without a claim form or EOB attached. We receive a large amount of documentation daily and will be unable to attach receipts without any identifying information.
61. I lost my receipts – can I still file a claim?
No. We are required to follow strict accounting rules and regulations set forth by the IRS and other Trustee Agreements, and therefore, require receipts to reimburse all purchases and services.
63. What is an Explanation of Benefits (EOB)?
An Explanation of Benefits or EOB is a statement from your insurance provider that provides details on claims that have been filed on your behalf. It typically shows the services rendered, date of service, patient’s name, provider’s name, and covered or uncovered charges, including co-pay and/or co-insurance amounts. You will typically receive an EOB from Empire after a service is complete, or you can download your EOB online by registering at www.empireblue.com.
VHHSBP also provides members with EOBs once a claim has been filed. The EOB will include date of service, member’s name, amount paid toward claim, and a corresponding check, if a payment was made. If no payment is made, your EOB will include information detailing why your claim was denied.