HR: Benefits: Trust Fund Employees
Medical and Dental Insurance
 

Eligibility Requirements

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 your enrollment via Smithsonian's online benefits administration portal administered by Secova. Smithsonian's Online Benefits Enrollment Quick Guide provides login and enrollment instructions. It is important to note that employees are responsible for monitoring their pay statements to ensure that payroll deductions are accurate. If questions on payroll deductions arise, employees should contact the SAO Benefits Office at (617) 495-7371 without delay.

Eligible dependent children are covered until 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. To change your coverage due to one or more of the qualifying life event (QLE) changes listed below, you will need to make the change using the Secova online enrollment portal at the Life Event tab. Documentation to justify the QLE must be uploaded to Secova for review and to avoid delay in effecting the change, the employee must notify the SAO Benefits Office by email of the change awaiting approval.

(1) Open enrollment - eligible employees may make changes to their medical, dental, vision or flexible spending accounts 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 usually 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. Changes must be initiated within 31 days of the qualifying event. A copy of the marriage certificate, court decree or death certificate will be required.

(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. Changes must be initiated within 31 days of the qualifying event. A copy of the child's birth certificate, adoption/placement documentation, or other relevant documentation will be required.

(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 initiated 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 life 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.

Benefit Choices

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 $250 per individual and $500 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. 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 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 CVS/Caremark 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

Blue Rewards Flyer

Plan Booklet

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 $20. Emergency room visits have a $150 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 Walgreens, 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.

Schedule of Benefits

Summary of Benefits and Coverage (SBC)

Walgreens Mail Order Form

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 Smithsonian's Delta Dental microsite 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

Benefits Summary

Claim Form

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.

VSP Plan Summary

Certificate of Coverage

Cost

SAO makes a substantial contribution to your health premiums. Click here for 2015 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 initiating the enrollment/change at the Secova website, except as noted below:

  1. Open enrollment changes are effective on January 1st of the new year.
  2. A QLE 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.
  3. 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 employee initiates the cancellation at the Secova website.

 
 

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