Health Insurance Coverage

On July 1, 2002, the State System of Higher Education began to use Highmark Blue Shield as its health vendor for the traditional indemnity (Classic Blue) and Point of Service (POS) programs for the faculty members.

Faculty members have three basic health plans to choose from when selecting their health plan coverage. These are as follows: (1) Classic Blue Traditional Indemnity, (2) Point of Service Plan which is designated by region in which your reside - (Select Blue of Western PA, Select Blue of Central PA, Blue Choice (Southeastern PA) and First Priority (Northeastern PA) and, (3) Health Maintenance Organization (HMO) – where such programs are available in PA based on residence.

Precertification is required under the Classic Blue Traditional program. Precertification has three components: presurgical certification, preadmission and admission certifications.

Highmark Blue Shield medical benefits program requires precertification of all elective surgical, medical and psychiatric in-hospital admissions. Precertification is required except for urgent and emergency in-hospital admissions which need to receive admission certification within 48 hours after admission occur or as soon as reasonably possible.

The following are the non-emergency elective surgeries, which require presurgical certification:

• Hysterectomy
• Prostrate Surgery
• Knee Surgery
• Cholecystectomy (removal of gall bladder)
• Tonsillectomy-Adenoidectomy
• Spinal and Vertebral Surgery
• Hemorrhoidectomy
• Cataract Surgery
• Coronary Artery By-Pass
• Bunionectomy
• Ligation and Stripping of Varicose Veins
• Submucous Resection (repair of deviated septum)
• Herniorrhaphy (hernia repair)

The toll-free number for providers and hospital/facilities to use to contact the Health Management Services who conduct precertification review is 1-866-727-4935.

Highmark Blue Shield (HOSPITAL)
The Blue Shield hospital/facility contract covers those charges that are incurred by you, your spouse and/or dependents as an in-patient. If the hospital/facility participates with the Blue Cross/Blue Shield association network, the hospital/facility will be directly reimbursed and the amount will be accepted as payment in full. If the hospital/facility does not participate, the subscriber/patient will receive direct payment and subscriber/employee will be liable for any balance over the allowance for the services rendered. These charges may be submitted to your major medical plan for consideration.

Highmark Blue Shield (MEDICAL-SURGICAL)
Blue Shield’s medical-surgical contract cover physician services (i.e., in-office surgeries), laboratory tests, x-rays, etc. If the physician/laboratory charges are incurred via a participating provider (under contract with a BC/BS association network), the amount reimbursed will be sent directly to the provider and will be accepted as payment in full. If the physician/lab is not a participating provider, the subscriber/patient is liable for any balance over the Blue Shield allowance for the services rendered. The reimbursement will be made payable directly to the subscriber/employee. These charges may be submitted to your major medical plan for consideration.

Highmark Blue Shield (Major Medical)
There are additional benefits that can be reimbursed directly to the subscriber under the Major Medical portion of your plan. Under Major Medical, the subscriber pays directly for all prescription drugs (see NPAY voluntary RX card section) and submits the claim to Major Medical for reimbursement. Doctor’s office visit (participating), including medical, chiropractic and psychiatric, will be billed electronically to Blue Shield and will be review and reimbursed under the Major Medical plan. Those non-participating charges will need to be paid directly to the provider and submitted to major medical by the subscriber/employee. As of January 2, 1999, all active faculty have a $250.00 yearly deductible. The family deductible is $750.00 – three family must, separately, satisfy the annual $250.00 deductible, once an individual family member satisfies this deductible, Major Medical will pay at 80%. The 4th person will begin to be reimbursed at 80% beginning with the first claim submitted.

The following are some of the services reimbursed under Major Medical:

• Whole Blood Components
• Prescription Drugs
• Artificial Limbs and Eyes
• Emergency Ambulance Service (Independently owned)
• Allergy Testing
• In-office Physician Fees (diagnosis required)
• Psychiatric Visits
• Chiropractic Care

Please remember that the above-referenced benefits/services represent only a partial listing and do not reflect the total range of benefits/services available to the State System of Higher Education/APSCUF faculty members.

HEALTH MAINTENANCE ORGANIZATION (HMO)
The State System of Higher Education has contracted with several HMO’s across the Commonwealth. Most services are paid in full when using the primary care physician (PCP). If an individual uses medical services without obtaining approval from their PCP, no reimbursement will be made.

Health benefit coverages vary from HMO to HMO, as well as the prescription drug plans where applicable. HMO’s typically cover the following: in and out patient facility services, medical/surgical services, preventative services and office visits. Co-payments for certain services obtained may be applicable. These co-payments vary from service to service and from HMO to HMO.

POINT-OFSERVICE (POS)
Faculty members were offered another option for health coverage beginning July 1, 1997. The State System of Higher Education made available a new point of service plan. There are four (4) plans in the Commonwealth of PA: Select Blue (Western), First Priority (Northeastern), Blue Choice (Philadelphia) and Select Blue (Central). A point of service plan is a type of managed care program where a primary care physician must be selected. Prescriptions are covered under Highmark Blue Shield. Faculty enrolled under the POS/RX Plan must satisfy a $100.00 annual deductible prior to having the 80% payment. Faculty are responsible for the 20% co-pay. However, unlike an HMO, a POS does provide for “self-referred” or “out-of-network” reimbursement. If an individual uses medical services without obtaining approval from their PCP, the POS will reimburse 80% of the charges after the $100.00 deductible is satisfied.

The POS service plans vary from plan to plan. Co-pays apply to certain services and these also vary by the service. Services covered include, but are not limited to: inpatient and outpatient facility services, medical/surgical services, preventative services and office visits. Please remember that the above-mentioned benefits/services represent only a partial listing and do not reflect the total range of benefits/services available to the State System of Higher Education/APSCUF faculty members.

For current information, please refer to the latest edition of the employee benefits handbook provided by your employer. If you have any questions, please contact your local human resource office. In addition, if you have enrollment questions or problems with any of the Highmark Blue Shield plans, the State System has a dedicated customer service line for its employees, toll-free nationwide, 1-866-727-4935. For customer service numbers for the HMO plans, please refer to the employees benefit handbook.

NPAY PRESCRIPTION DRUG PROGRAM
All faculty, their spouses and dependent children enrolled in the Classic Blue Traditional Indemnity Plan, Highmark Blue Shield, are eligible to participate in the NPAY discount pricing program AND the CFI mail order pharmacy service program. The programs are simple to use. Call 800-233-7139 for information. The Benefits Coordinator in your local human resources office is also available to answer questions.

STATE EMPLOYEE ASSISTANCE PROGRAM (SEAP)
All faculty, their spouses and children are eligible to participate in this no cost program. All services are provided in a totally confidential manner. To talk with a skilled counselor, all your needs to do is call 800-692-7459 or TDD 800-824-4306. The program provides a wide range of services to help treat a broad range of problems. SEAP is for everyone in the family and any family member may access the program. All SEAP counselors have a clinical master’s degree with at least four (4) years of actual clinical experience. Please note that some counselors may not be considered and eligible provider under Highmark Blue Shield, if the sessions extend beyond the “free” session. To obtain a brochure describing the services provided by the SEAP program, you may visit your local APSCUF office.

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