Town of Guadalupe Medical Benefits

An EPO plan offers coverage when you utilize the services of the contracted EPO network of medical providers. AzMT has contracted with Blue Cross Blue Shield of Arizona (BCBSAZ) as its EPO network of providers. No benefits are payable for services obtained outside of the EPO network except in the case of a life-threatening emergency that occurs while you are traveling outside of the EPO network.

A PPO plan generally offers two (2) levels of coverage – in-network and out-of-network. The “in-network” level of coverage is applicable when you utilize the services of the contracted PPO network of medical providers. AzMT has contracted with Blue Cross Blue Shield of Arizona (BCBSAZ) as its PPO network of providers. The “in-network” level of benefits is the highest level of benefit offered by the Plan. “Out-of-network” benefits apply when a provider that is not contracted with BCBSAZ is utilized for care or treatment. The “out-of-network” benefits are not as rich as the “in-network” benefits, and therefore utilization of “out-of-network” providers will increase your out-of-pocket costs for medical care and treatment.

A high-deductible health plan is a plan with a minimum annual deductible and a maximum out-of-pocket limit. These minimums and maximums are determined annually by the Internal Revenue Service (IRS) and the Trust Board sets the limits for the AzMT plan within those guidelines.

Please refer to the SBC or SPD specific to the HDHP for more information about the HDHP plan offered by AzMT.

A deductible is the amount of medical expenses you are responsible for paying before your insurance starts covering you. The deductible amount can be found in the AzMT Summary Plan Description (SPD) booklets, which are available through your Human Resources Department, and also on this website.

A co-payment is a fixed-dollar amount that you are responsible for paying for a particular medical service. Co-payment services generally do not require the satisfaction of a deductible before payment can be made. AzMT co-pay amounts can be found in the AzMT Summary Plan Description (SPD) booklets, which are available through your Human Resources Department, and also on this website.

Yes

Coinsurance is the cost of a medical service that you are responsible for paying after satisfaction of the annual deductible. Unlike a co-payment, which is a fixed-dollar amount, coinsurance is expressed as a percentage. AzMT’s coinsurance amounts can be found in the AzMT Summary Plan Description (SPD) booklets, which are available through your Human Resources Department, and also on this website.

An out-of-pocket expense is any cost you have to pay yourself when receiving medical care. This includes your deductible, co-payments, and coinsurance. Most health insurance policies have an annual maximum out-of-pocket expense. Once you’ve paid out enough money to meet that maximum, your insurance company will pay the rest of your eligible major medical expenses for the remainder of that plan year. There are separate out-of-pocket maximums for medical claims and prescriptions, as outlined in your Summary Plan Description (SPD).

It depends on which Plan you have selected to participate in, however, AzMT contracts with medical providers through Blue Cross Blue Shield of Arizona (BCBSAZ) for all of the plans it offers.

 You can easily locate a provider by searching the provider directory at www.azblue.com/CHSnetwork or by calling (800) 232-2345.

No. None of the AzMT medical plans require the utilization of a primary care physician. At the time you need a medical service you determine which type of provider is most appropriate for the condition being treated.

When a person is covered by more than one benefit plan (for example, a child who is covered by both parents’ programs), which is known as dual coverage, the two sets of benefits are coordinated so that no more than 100 percent of the total covered expense is paid.

The Trust has contracted with AmeriBen as its Claims Administrator. AmeriBen’s responsibilities include, but are not limited to, loading and verifying member eligibility, paying eligible claims and answering customer service related questions for AzMT members.

An EOB is a statement which lists the codes of the procedures performed, along with the date of service, amount billed, discount amount (if any), and the amounts payable by AzMT and the patient. EOB’s are sent for every claim processed by AmeriBen.

Yes, this is an option available to you through AmeriBen.   You may access your claims information by registering as a member at www.myameriben.com.

The medical benefit plan requires pre-certification of certain services. This program is designed as a cost containment measure through AmeriBen to maximize the Plan benefits and reduce unnecessary hospitalizations, surgical procedures, diagnostic and other services. Failure to comply with the pre-certification requirements will result in a $300 penalty, or may disqualify the Covered Person for benefits. It is always up to you, and the physician you choose, to determine what services you need and who will provide your care, regardless of what this Plan will pay for. Once a pre-certification is received, it is valid for ninety (90) days.

IMPORTANT:  Pre-certification of a procedure does not guarantee benefits.  All benefit payments are determined by AmeriBen in accordance with the provisions of this Plan.

Precertification is required for the following services:

• Inpatient admissions (surgical and non-surgical excluding routine newborn deliveries, longterm acute care, skilled nursing/rehabilitation facility, inpatient substance abuse/mental
  disorder treatments including residential facilities);
• Maternity admissions that exceed forty-eight (48) hours (ninety-six [96] hours for Cesarean
  Section);
• Outpatient surgical procedures (excluding outpatient office surgical procedures and screening
  colonoscopies);
• Advanced imagine (CT studies, Coronary CT angiography, MRI/MRA, nuclear cardiology,
  nuclear medicine and PET scans excluding services rendered in an ER setting);
• Outpatient rehabilitation services (physical, occupational and speech therapy) in excess of
  twenty (20) visits per plan year;
• Chemotherapy drugs/infusions and radiation treatments for oncology diagnoses;
• Home health care services and supplies;
• Transplants, including, but not limited to, kidney, liver, heart, lung and pancreas, and bone
  marrow replacement to stem cell transfer after high dose chemotherapy;
• Orthotics/Prosthetics over one thousand dollars ($1,000);
• Durable Medical Equipment over one thousand dollars ($1,000);
• Genetic testing/genomic testing (excluding amniocentesis);
• Clinical trials that are conducted in relation to the prevention, detection, or treatment of cancer
  or other life-threatening diseases or conditions;
• Specialty infusion/injectable medications provided in an outpatient facility, physician’s office
  or home infusion over one thousand dollars ($1,000);
• Behavioral therapy services for treatment of autism spectrum disorder; and
• Dental services required for medical procedures.

PLEASE REFER TO THE SUMMARY PLAN DOCUMENT FOR A CURRENT LIST OF SERVICES THAT REQUIRE PRE-CERTIFICATION!

What is the procedure for obtaining pre-certification?

For all non-emergency procedures that require pre-certification, the Covered Person or his/her Physician must contact AmeriBen prior to the admission or in advance of the procedure at 855.778.9053.  It is recommended that pre-cert is requested at least seventy-two (72) hours in advance.  AmeriBen will review the request for services and contact the Physician for any records or additional information necessary to thoroughly evaluate the need for services.

Benefit eligibility for the pre-certified procedures must be verified with AmeriBen prior to completing services.

For emergency procedures or hospital admissions, the Covered Person, his/her Physician, the hospital admissions clerk, or anyone associated with the Covered Person's treatment, must notify AmeriBen by telephone within forty-eight (48) hours of the procedure or the  admission.

In certain complex medical situations where many different doctors and/or treatments may be needed, case management may become necessary. A nurse case manager from AmeriBen may be assigned to work with the patient, the family, the Physician and the claims payor to coordinate an effective treatment plan.

A medical emergency means a sudden unexpected onset of a medical condition, which manifests itself by acute symptoms of sufficient severity that requires urgent and immediate medical attention (without regard to the hour of day or night) to prevent significant impairment in bodily functions or serious and/or permanent dysfunction of any bodily organ or part and is not normally treatable in the provider’s office.

If emergency medical care is rendered by a provider that is not part of the BCBSAZ participating provider network, as would be the case if you are traveling outside of Arizona or outside of the United States, services may be considered under the “In-Network” level of benefits, if it is determined by AmeriBen that immediate medical attention was required due to an accident or illness which is serious enough to constitute a medical emergency as outlined directly above.

You may contact AmeriBen Customer Care at (855) 350-8699.

The AzMT benefit plans include a benefit appeal process that is included in the Summary Plan Description (SPD) booklets, which are available through your Human Resources Department, and also on this website (see Plan Provisions).

You can request replacement cards by calling AmeriBen Customer Care toll-free at (855) 350-8699. You should receive your new card within 7 to 10 calendar days from the date of your request. You may also access a digital ID card through the MyAmeriBen Mobile App or you can print an ID card directly from the MyAmeriBen website at www.MyAmeriBen.com.