Group Medical Benefits
The following information comprises the Summary Plan Description to our employees under the Employees' Retirement Income Security Act of 1974 often referred to as ERISA. Refer to the Medical Benefit Plan Booklet for the complete Plan document.
Plan Administrator
This Welfare Benefit Plan is administered by Rhodes College, 2000 North Parkway, Memphis, TN 38112 whose Internal Revenue Service Employer Identification Number is EIN620476301. The Plan Number is 501. The plan year is July through June. This is a contract administration plan and the third party administrator (TPA) is Pittman & Associates. Information regarding Plan eligibility, enrollment, cost, and the procedure for applying for benefits is contained in this section. The Plan Booklet, which each covered employee receives, without cost, includes a description of benefits under the Plan and the conditions under which these benefits are available to covered individuals.
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Employees Eligible For The Plan
All full-time faculty and staff categories A and B are eligible to enroll in the Medical Benefit Plan. Part-time employees and their dependents hired after July 1, 1989 are not eligible for medical coverage.
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Date Eligible for Coverage
Each employee becomes eligible for medical coverage under the Plan the first day of the month following the date of employment with Rhodes.
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Pre-existing Condition
Clause
There is a 12-month pre-existing condition clause in the Medical Benefit Plan. A pre-existing condition is a condition for which medical advice, diagnosis, care, or treatment was recommended or received within six months of a person's enrollment date. For these purposes, genetic information is not a condition.
Treatment includes receiving services and supplies, consultations, diagnostic tests or prescribed medicines. In order to be taken into account, the medical advice, diagnosis, care, or treatment must have been recommended by, or received from, a physician.
The pre-existing condition does not apply to pregnancy, to a newborn child within 31 days of birth who is covered under creditable coverage, or to a child who is adopted or placed for adoption before attaining age 18 and who, as of the last day of the 31-day period beginning on the date of the adoption or placement for adoption, is covered under creditable coverage.
The prohibition on exclusion for newborn, adopted, or pre-adopted children does not apply to an individual after the end of the first 63-day period during all of which the individual was not covered under any creditable coverage.
The length of a pre-existing condition's limitation may be reduced or eliminated if an eligible person has creditable coverage from another health plan.
An eligible person may request a certificate of creditable coverage from his or her prior plan. If, after creditable coverage has been taken into account, there was still a pre-existing condition limitation imposed on an individual, that individual will be so notified by the Third Party Administrator, Pittman & Associates.
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Creditable Coverage
As required by the Health Insurance Portability and Accountability Act (HIPAA) certificates of coverage will be provided without charge for covered employees or dependents covered under Rhodes College Medical Benefit Plan.
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Date Eligible for Dependent
Coverage
A dependent shall become eligible for coverage on either (a) the first day that the employee becomes eligible for coverage and satisfies the definition of eligible dependent coverage or (b) the day a covered employee first acquires an eligible dependent. New dependents must be added to your medical coverage within 30 days of the event (i.e., marriage, birth, etc.). The definition of the dependents eligible for coverage under this Plan appears in the
Medical Benefit Plan Document (PDF).
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Enrolling in the Plan
An employee and his or her dependents may become covered on the date of first eligibility. Enrollment forms, which should be completed promptly, may be obtained from the Human Resources Office. Additional information about enrollment procedures, including special enrollment periods, may also be obtained from the Director of Human Resources.
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Plan A -- PPO Benefits
- 100% coverage after $25 office co-payment on physician's charges if you see a physician participating in the Baptist PPO and/or use the Baptist Minor Medical Clinics.
- Diagnostic X-Ray and lab charges are paid at 80% for PPO providers.
- $400 calendar year deductible per person (family maximum of 3). See complete schedule of benefits for list of items that apply to deductible.
- 80% coverage for eligible expenses after the deductible has been met.
- 100% coverage on all eligible expenses after $1,500 (plus deductible and co-payments) has been paid out-of-pocket by the covered person.
- $1,000,000 lifetime maximum.
- 12-month pre-existing condition clause.
- Well baby and well adult care.
- Pre-admission certification is required for hospital admissions.
- Inpatient care for mental and nervous disorders are limited to 15 days per calendar year maximum and 80% of all other covered medical expenses, after the deductible has been met. These expenses do not apply toward the out-of-pocket maximum.
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Plan A -- Non-PPO Benefits
- $500 calendar year deductible per person (family maximum of 3). All eligible expenses apply toward the deductible except prescription drug co-payments if purchased from a network pharmacy.
- 50% coverage on eligible expenses after the deductible has been met.
- No out-of-pocket maximum.
- $1,000,000 lifetime maximum.
- 12-month pre-existing condition clause.
- Pre-admission certification is required for hospital admissions.
- Inpatient care for mental and nervous disorders are limited to 15 days per calendar year maximum and 50% of all other covered medical expenses, after the deductible has been met. These expenses do not apply toward the out-of-pocket maximum.
Click here for a Schedule of Benefits
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Plan B -- PPO Benefits
- $750 calendar year deductible per person (family maximum of 3). All eligible expenses apply toward the deductible except well child and well adult care ad prescription drug co-payments if purchased from a network pharmacy.
- 80% coverage on eligible expenses after deductible has been met.
- 100% coverage on all eligible expenses after $2,500 (plus deductible and co-payments) has been paid out-of-pocket by the covered person.
- $1,000,000 lifetime maximum.
- 12-month pre-existing condition clause.
- Pre-admission certification is required for hospital admissions.
- Inpatient care for mental and nervous disorders are limited to 15 days per calendar year maximum and 80% of all other covered medical expenses, after the deductible has been met. These expenses do not apply toward the out-of-pocket maximum.
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Plan B -- Non-PPO Benefits
- $1,000 calendar year deductible per person (family maximum of 3). All eligible expenses apply toward the deductible except prescription drug co-payments if purchased from a network pharmacy.
- 50% coverage on eligible expenses after deductible has been met.
- No out-of-pocket maximum.
- $1,000,000 lifetime maximum.
- 12-month pre-existing condition clause.
- Pre-admission certification is required for hospital admissions.
- Inpatient care for mental and nervous disorders are limited to 15 days per calendar year maximum and 50% of all other covered medical expenses, after the deductible has been met. These expenses do not apply toward the out-of-pocket maximum.
Click here for a Schedule of Benefits
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Applications, Requests, and Questions Directed to the Plan Administrator
Applications, requests, and questions regarding enrollment, participation, or other administrative matters and service of legal process on issues arising from such questions, should be directed to the Plan Administrator, Director of Human Resources, Rhodes College, 2000 North Parkway, Memphis, TN 38112, 901-843-3750.
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The Cost of the Plan
Effective July 1, 1989, employees will be responsible for sharing in the cost of the Medical Benefit Plan through a medical benefit premium payment. At the employee's option, medical benefit premium payments can be deducted through a flexible benefits program (pre-tax option).
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How to Submit a Claim
When a Covered Person has a claim to submit for payment, that person must:
- Obtain a claim form from the Human Resources Office or the Plan Administrator.
- Complete the Employee portion of the form. All questions must be answered.
- Have the Physician complete the provider's portion of the form.
- For Plan reimbursements, attach bills for services rendered. All bills must show:
- Name of Plan
- Group number
- Employee's name
- Name of patient
- Name, address, telephone number of the provider of care
- Diagnosis
- Type of services rendered, with diagnosis and/or procedure codes
- Date of services
- Charges
Send the above to the Claims Administrator at this address: Pittman & Associates, Inc. P.O. Box 111047 Memphis , TN 38111 (901) 473-3100.
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When Claims Should Be Filed
Claims should be filed with the Claims Administrator within 90 days of the date charges for the service was incurred. Benefits are based on the Plan's provisions at the time the charges were incurred. Charges are considered incurred when a treatment or care is given or a procedure performed. Claims filed later than that date may be declined or reduced unless:
- It is not reasonably possible to submit the claim in that time; and
- The claim is submitted within one year from the date incurred. This one-year period will not apply when the person is not legally capable of submitting the claim.
The Claims Administrator will determine if enough information has been submitted to enable proper consideration of the claim. If not, more information may be requested from the claimant. The Plan reserves the right to have a Plan Participant seek a second medical opinion.
A request for Plan benefits will be considered a claim for Plan benefits, and it will be subject to a full and fair review. If a claim is wholly or partially denied, the Claims Administrator will furnish the Plan Participant with a written notice of this denial. This written notice will be provided within 90 days after receipt of the claim. The written notice will contain the following information:
- The specific reason or reasons for the denial;
- Specific reference to those Plan provisions on which the denial is based;
- A description of any additional information or material necessary to correct the claim and an explanation of why such material or information is necessary; and
- Appropriate information as to the steps to be taken if a Plan Participant wishes to submit the claim for review.
A Plan Participant will be notified within 90 days of receipt of the claim as to the acceptance or denial of a claim and if not notified within 90 days, the claim shall be deemed denied.
If special circumstances require an extension of time for processing the claim, the Claims Administrator shall send written notice of the extension to the Plan Participant. The extension notice will indicate the special circumstances requiring the extension of time and the date by which the Plan expects to render the final decision on the claim. In no event will the extension exceed a period of 90 days from the end of the initial 90-day period.
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Claims Review Procedure
In cases where a claim for benefits payment is denied in whole or in part, the Plan Participant may appeal the denial. This appeal provision will allow the Plan Participant to:
- Request from the Plan Administrator a review of any claim for benefits. Such request must include: the name of the Employee, his or her Social Security number, the name of the patient and the Group Identification Number, if any.
- File the request for review in writing, stating in clear and concise terms the reason or reasons for this disagreement with the handling of the claim.
The request for review must be directed to the Plan Administrator or Claims Administrator within 60 days after the claim payment date or the date of the notification of denial of benefits.
A review of the denial will be made by the Plan Administrator and the Plan Administrator will provide the Plan Participant with a written response within 60 days of the date the Plan Administrator receives the Plan Participant's written request for review and if not notified, the Plan Participant may deem the claim denied. If, because of extenuating circumstances, the Plan Administrator is unable to complete the review process within 60 days, the Plan Administrator shall notify the Plan Participant of the delay within the 60 day period and shall provide a final written response to the request for review within 120 days of the date the Plan Administrator received the Plan Participant's written request for review.
The Plan Administrator's written response to the Plan Participant shall cite the specific Plan provision(s) upon which the denial is based.
A Plan Participant must exhaust the claims appeal procedure before filing a suit for benefits.
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Amendment to the Medical Benefit Plan
Rhodes shall be the Administrator for this Plan, and as such, shall have the authority to control and manage the operation and administration of the Plan. The Administrator has designated in writing the Director of Human Resources to carry out duties under the Plan.
The Board of Trustees reserves the right to modify or discontinue the Plan at any time.
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