To be eligible to participate in health benefits, you must have a regularly scheduled tour of duty of at least 40 hours per pay period and be serving under an indefinite appointment or temporary appointment of 90 days or more.
If you enroll within the first 60 days of employment, the effective date of your insurance will be the first pay period following receipt of your application(s) in the SAO Benefits Office.
Beginning January 1, 2011, an eligible dependent child is covered until he/she reaches age 26, regardless of whether the child is a full-time student, married or even claimed as your own tax dependent.
Employees who want coverage must enroll within 60 days of initial appointment, unless covered by one of the exceptions listed below applies.
Events Which Allow Enrollment/Changes
Listed below are qualifying events that allow changes to be made to your health insurance coverage:
(1) Open enrollment - eligible employees may make changes during Open Enrollment Season, which begins during November of every year. Plan changes made at this time will be effective on the January 1st of the new year. Payroll deductions will be effective the pay period in which the first day of the new year occurs.
(2) Changes in legal marital status - events that change an employee's legal marital status include marriage, death of spouse, divorce, legal separation, or annulment. Change forms must be received within 31 days of the qualifying event.
(3) Change in number of dependents - events that change an employee's number of dependents include birth, adoption, placement for adoption (as defined in HIPAA regulations), or death of a dependent. Change forms must be received within 31 days of the qualifying event.
(4) Change in spouse's employment status or group health plan - a termination or commencement of employment by the employee's spouse. New enrollments and changes must be received within 31 days of the change in the spouse's coverage. Written proof of a spouse's change in insurance status will be required.
(5) Change in work schedule and/or appointment- a reduction or increase in hours of employment by the employee. New enrollments and changes must be received within 31 days of the date that the change occurs.
(6) Change in dependent status - dependent satisfies or ceases to satisfy the requirements for eligible dependents due to attainment of age, or any similar circumstance under the plan that qualifies or disqualifies a dependent for coverage.
(7) Change in residence or worksite - a change in the place of residence or work of the employee, which would make him/her ineligible under his or her current plan.
NOTE: If you are enrolled in the Flexible Benefit Plan (pre-tax health premiums), once you make your health insurance election(s) for any one calendar year, you may not make any changes until the next Open Enrollment Season, unless you experience one of the qualifying events listed above. If you are not enrolled in the Flexible Benefit Plan, you may change from family to self only or cancel your coverage at any time.
Eligible Trust Fund employees may choose from the following plans, summarized below:
The CareFirst BlueCross/BlueShield Preferred (PPO) Plan is a plan that allows employees to obtain medical care within a preferred network of providers who have contracted at reduced rates with the carrier. This plan affords the freedom of choice to obtain medical care outside the network by paying a higher deductible ($500 per individual and $1,000 maximum per family per calendar year) and coinsurance (generally 30% of the allowed benefit).
The in-network deductible that applies to most services, except for Preventive, is $300 per individual and $600 maximum per family per calendar year and coinsurance for most services is 10% of the allowed benefit. In-network Preventive services, such as routine physical exams, are not subject to the deductible or copayment.
The annual out-of-pocket limit that an employee will pay in one calendar year to in-network providers is $1,500 for individual coverage and a maximum of $3,000 for family coverage. The out-of-network out-of-pocket maximum is $3,000 for individual and a maximum of $6,000 for family coverage. The coinsurance percentage for outpatient mental health services varies. Refer to the plan summary for specifics. The lifetime maximum for covered services is unlimited.
You are not required to choose a primary care physician or obtain referrals to specialists. Beginning January 1, 2011, cost sharing (copayments, coinsurance and deductibles) is eliminated for in-network preventive services. Annual limits are removed for most services, including prescription drug plans, and lifetime limits on medical benefits are removed. If you use a provider in the network, there is no deductible; you pay a $20 copayment for an office visit for illness. For in-network diagnostic services, x-ray and lab testing, surgical care and anesthesia, ambulance, and allergy testing, you must first satisfy the in-network deductible, and then most services are covered at 90%. If you use a non-network provider, you must pay the deductible before any reimbursement is made, and most services are covered at 70%. You must submit claim forms for all non-network providers. Emergency room copayment is $100 per visit, but will be waived if admitted.
The copayments for the PPO pharmacy network (Argus) at retail pharmacies, filled with a 34-day supply:
- Generic - $10
- Retail preferred brand - $30
- Non-preferred brand - $55
- Injectables - 50% up to $75 maximum.
Mail order maintenance drug prescriptions are filled by Walgreens Mail Service with a 90-day supply. Copayments are:
- Generic - $20
- Preferred brand - $60
- Non-preferred brand - $110
- Injectables - 50% up to $150 maximum.
Please contact CareFirst PPO Customer Service at 1-800-321-3497 with any questions.
Summary of Benefits and Coverage (SBC)
Prescription Drug Summary
CareFirst PPO Certificate of Coverage
Claim Form for MA
Claim Form for AZ
Claim Form for HI
IMPORTANT: The Health Insurance Portability and Accountability Act (HIPAA) allows for the waiver of some or all of any pre-existing condition limitation period if a break in coverage is 63 days or less. If you enroll in the CareFirst Blue Cross/Blue Shield PPO plan and you were covered under a previous group health plan, please provide CareFirst with a copy of your HIPAA certificate when you file your first insurance claim.
Harvard Pilgrim Health Care (HPHC) is an HMO plan with a network of private practice physicians, specialists, and other medical providers. You must choose a primary care physician (PCP) from a private office, a health center, or a multi-specialty group practice. The PCP you choose will coordinate your health care needs, provide referrals to specialists and order diagnostic tests. HPHC only pays for services that are either provided or authorized in advance by HPHC clinicians (there are certain exceptions for emergency situations as defined by the plan).
Copayments for physician office visits for illness are $15. Emergency room visits have a $100 copayment. Hospital stays and day surgery in a hospital setting are subject to a copayment of $50 per day up to $250 per calendar year. Hospital outpatient services are covered in full.
The copayments for prescriptions purchased at a network retail pharmacy having a 30-day supply are:
- Lower cost generic - $5
- Higher cost generic - $20
- Select brand name - $30
- Non-select brand name - $50
Mail order prescriptions, having a 90-day supply, are filled through Bioscrip Pharmacy, with copayments as follows:
- Lower cost generic - $10
- Higher cost generic - $40
- Select brand name - $60
- Non-select brand name - $150
Please contact HPHC Member Services at 1-888-333-4742 with questions. Click here for a Provider Directory.
Summary of Benefits and Coverage (SBC)
Prescription Drug Summary
Prescription Drug FAQ
Tier 1 Drug List
Delta Dental Preferred is a dental plan that allows employees to obtain dental care services from a network of dentists. It also affords employees the option of obtaining dental care outside the network. When you choose a network dentist from either the Preferred or Premier Delta Dental networks, reimbursement will be based on lower contracted rates. When you choose a non-network dentist, reimbursement will be based on a "reasonable and customary" fee schedule. Network dentists will file claims with Delta Dental on your behalf. If you go to a non-network dentist, you may need to file your own claim forms. The plan will pay up to $1,500 in benefit payments per person per calendar year and the orthodontia lifetime limit is $2,000 per eligible dependent child. Certain services are subject to a $50 deductible per calendar year. You do not need to be enrolled in an SAO-sponsored medical plan to enroll in the dental plan.
Contact Delta Dental Customer Service at 1-800-932-0783. Click
here to access the Delta Dental website to locate a network dentist. Remember to enter the state where you reside or where you will see a dentist.
Evidence of Coverage and Pregnancy Amendment
Vision Services Plan (VSP) provides coverage for eye exams, spectacle or contact lenses and frames if you visit a VSP participating doctor. Out-of-network benefits are provided if you see a non-VSP provider, as well. You do not need to be enrolled in one of the medical plans to enroll in the vision plan. Please note: Both CareFirst PPO and Harvard Pilgrim provide benefits for annual eye exams and both offer discounts on eyewear and contact lenses.
Contact VSP at 1-800-877-7195 with questions, or go online to http://www.vsp.com for information.
2013 VSP Plan Summary
Certificate of Coverage
SAO makes a substantial contribution to your health premiums. Click here for 2013 employee premiums and SAO contributions. Employees will be notified of annual rate changes during Open Enrollment Season, which occurs every November.
Enrollments/Changes - Effective Dates
Enrollments or changes are effective the first day of the pay period after enrollment/change forms are received in the SAO Benefits Office, except as noted below:
- Open enrollment changes are effective on January 1st of the new year.
- A change made in conjunction with the birth of a child, or addition of a child as a new family member, is effective the day on which the child is born or becomes a family member.
- Harvard Pilgrim Health Care changes made in conjunction with a marriage are effective on the date of marriage.
Normally, the corresponding rate change for these exceptions occurs on the first day of the pay period in which the effective date falls.
Note for new hires: Although you have 60 days from your effective date of employment to enroll, the earliest your coverage can become effective is the first day of the pay period following your entrance on duty.
Leave Without Pay (LWOP)
Medical and dental coverage may remain in effect if elected while you are on LWOP for up to one year. The Smithsonian Astrophysical Observatory will continue its contribution and your contribution during this period. You are responsible for repaying your share of the premiums paid on your behalf by SAO, and you will be notified of the available options for repayment when you are billed directly for these premiums by the National Finance Center (SAO's payroll administrator).
Termination of Enrollment or Coverage
Coverage of an enrolled employee continues for 31 days after employment terminates for any reason except voluntary cancellation or a change of status resulting in ineligibility for health insurance. A voluntary cancellation takes effect on the last day of the pay period in which the SAO Benefits Office receives your written cancellation.