HR: Benefits: Trust Fund Employees
Medical, Dental and Vision 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.

The Smithsonian Institution follows the requirements for providing health insurance coverage as outlined in the Affordable Care Act (ACA). Employees who do not currently meet Smithsonian's eligibility requirements as stated above, may be eligible to enroll in Trust health insurance (medical only) in the future when they meet the Affordable Care Act (ACA) eligibility criteria.

Eligible dependents include the employee's legal spouse and/or the employee's children. An eligible dependent child is covered until age 26, regardless of whether the child is a full-time student, married or even claimed as your own tax dependent. In order for the overage dependent to receive information on continuation of coverage, the employee must complete a Change in Family Status Qualifying Life Event via Secova's online employee self-service enrollment portal. Please refer to the section on COBRA for more details.

 

Enrollment

Employees must enroll within 60 days of appointment or from the date you are initially eligible for coverage (e.g., a change in work schedule) via the online employee self-service portal at http://ielect.Secova.com. Smithsonian's Online Benefits Enrollment Quick Guide provides login and enrollment instructions.

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. 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 SAO-Benefits@cfa.harvard.edu without delay.

Employees who want coverage must enroll within 60 days of initial appointment, unless 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 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 calendar year, you may not make any changes until the next Open 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.

 

Plan Choices

Eligible Trust Fund employees may choose from the following plans, summarized below:

 

The CareFirst BlueCross/BlueShield Preferred (PPO) Plan is a plan that affords employees the most flexibility to obtain medical care, as this plan has a nationwide network of preferred providers that have contracted at reduced rates with the carrier. This plan offers 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, 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 Pharmacy Program has a deductible of $100 per person/$200 per family. The copayments for the PPO pharmacy network are based upon the drug tier as follows when prescriptions are filled (34-day supply) at a retail pharmacy:

  • Tier 1 - Generic - $10
  • Tier 2 - Preferred brand - $30
  • Tier 3 - Non-preferred brand - $55
  • Tier 4 - Self-administered 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:

  • Tier 1 - Generic - $20
  • Tier 2 - Preferred brand - $60
  • Tier 3 - Non-preferred brand - $110
  • Tier 4 - Self-administered Injectables - 50% up to $150 maximum.

For details on filling prescriptions, refer to the CareFirst website.

Please contact CareFirst PPO Customer Service at 1-800-321-3497 with any questions.

Summary of Benefits and Coverage

Summary of Benefits

Pharmacy Summary

Vision Summary

Plan Booklet

Member Benefit Guide

CareFirst Notice of Nondiscrimination and Available Language Assistance

Claim Form for MA

Claim Form for AZ

Claim Form for HI

 

Harvard Pilgrim Health Care (HPHC) is an HMO plan with a network of private practice physicians, specialists, and other medical providers serving Massachusetts, New Hampshire and limited access in Maine. You must choose a primary care physician (PCP) from HPHC's network of doctors in private practice, 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).

Diagnostic services and certain other services are subject to a deductible of $1,000 per individual and $2,000 per family. Routine preventive care appointments are free of charge. Copayments for primary care and specialist office visits for illness/injury are $25. Each emergency room visit is subject to the deductible and has a $150 copayment. Emergency medical transportation is subject to the deductible, then no charge. High tech medical imaging (advanced radiology) is subject to the deductible and has a $150 copayment per procedure. Hospital stays and day surgery in a hospital setting are subject to the deductible, then no charge. Physician/surgeon fees in a hospital or surgi-center are subject to the deductible, then no charge. Hospital outpatient services are also subject to the deductible. Urgent Care clinics have a $25 copayment per visit.

The copayments for prescriptions purchased at a network retail pharmacy having a 30-day supply are based upon a 5-tier Value Formulary structure:

  • Tier 1 - Lower cost generic - $10
  • Tier 2 - Higher cost generic - $30
  • Tier 3 - Select brand name - $50
  • Tier 4 - Non-select brand name - $75
  • Tier 5 - Non-preferred specialty drugs and higher cost brand name - 20% coinsurance up to $250 maximum per prescription or refill.

Mail order prescriptions, having a 90-day supply, are filled through MedImpact, with copayments as follows:

  • Tier 1 - Lower cost generic - $20
  • Tier 2 - Higher cost generic - $60
  • Tier 3 - Select brand name - $100
  • Tier 4 - Non-select brand name - $150
  • Tier 5 - Non-preferred specialty drugs and higher cost brand name - 20% coinsurance up to $750 maximum per prescription or refill.

Please contact HPHC Member Services at 1-888-333-4742 with questions. Click here to look up a Primary Care Physician (PCP) or other Plan Provider.

Schedule of Benefits

Summary of Benefits and Coverage (SBC)

Prescription Drug Summary

Plan Booklet

Prescription Drug FAQ

 

Delta Dental PPO Plus Premier plan is a nationwide 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 PPO or Premier Delta Dental networks, reimbursement will be based on lower contracted rates and you will result in a lower out-of-pocket expense. 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 deductible per calendar year. If you go to a dentist participating in the PPO or Premier network, the annual deductible is $50 per person/$150 per family deductible each calendar year. If you go to a non-network dentist, the annual deductible is $75 per person/$225 per family 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

Delta Dental Certificate of Coverage

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 2019 employee premiums and SAO contributions. Employees are notified of annual rate changes during Open 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, a change of status resulting in ineligibility for health insurance, or disability continuants. A voluntary cancellation takes effect on the last day of the pay period in which the employee initiates the cancellation at the Secova website. -Employees do not receive the 31 day extension of benefits under the vision plan. Vision plan benefits end the lst day of the pay period in which you worked.

 
 

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