HealthNow Plan
The HealthNow Plan does not require participants to select a primary care physician (PCP), but strongly encourages members to keep in contact with their PCP. The HealthNow Plan allows you two choices each time you seek medical care:
- If you go to a participating provider, you will receive preferred benefits "in network." In general, you will pay $12 per office visit and 10% of other services, with no deductible applied. Your annual out-of-pocket maximum for eligible medical expenses is capped at $1,500/individual or $3,000/family.
- You can seek medical care at a non-participating provider (out of network). After meeting your deductible ($300/individual or $750/family), your eligible expenses are generally reimbursed at 70% subject to reasonable and customary charge as determined by HealthNow. Your annual out-of-pocket maximum for eligible medical expenses is capped at $3,000/individual or $6,000/family.
Eligibility
You are eligible to participate in the HealthNow Plan as of the day your
employment begins if you are:
- a regular full-time staff member (appointed at least 35 hours per week for not less than six months) of the endowed colleges and units
- a member of the faculty or academic staff staff of the endowed colleges (appointed at least one full semester at full-time)
- a regular part-time staff member of the endowed colleges and units (appointed at least 20 - 34 hours per week) who will be appointed for at least six months; or for academic teaching staff, appointed at least one semester at half time.
- a temporary staff member appointed initially for six months or longer; if the initial appointment (under six months) is extended past six months with no break in service, the effective date of coverage is based on the date the appointment is extended
- a postdoctoral fellow or visiting fellow without salary in a contract college position
If you are represented by a bargaining unit, your health care benefits are subject to the provisions of your particular bargaining agreement. Please refer to your labor agreement for details on participation.
Who Is Eligible for Coverage?
Generally you, your spouse or same-sex partner (refer to Imputed Income)
and unmarried dependent children under age 19 are eligible for coverage.
Dependent children include biological children, adopted children, and
any other child you claim on your federal tax return who lives with you
in a parent-child relationship. Coverage for unmarried dependent children
may be extended to age 25 while they are full-time students. (Full-time
is defined as 12 or more credit hours.) Coverage for mental or physically
incapacitated children may also be continued, provided the disabling condition
occurs while the child is a covered dependent, for as long as the dependent
remains incapacitated.
A same-sex partnership is defined a two individuals of the same gender who live together in a long-term relationship of indefinite duration, with an exclusive mutual commitment in which the partners agree to be jointly responsible for each other's common welfare and to share financial obligations. If you wish to enroll your same-sex partner and/or partner's eligible child(ren), you and your partner need to sign and return a Statement of Same-Sex Partnership form to Benefit Services, 130 Day Hall.
Imputed Income Assessed on Same-Sex Partners
The value of the health benefits your same-sex partner receives is viewed
as taxable income based on the Internal Revenue Code (IRC). Same-sex partners
do not meet the IRS's definition of a dependent. When the employer provides
a benefit to someone other than a dependent (as defined by the IRC), the
value of the benefit provided must be calculated into the gross income
of the employee for tax purposes. Faculty and staff who cover a same-sex
partner should be aware that this may increase their federal and state
taxes.
The imputed income is the total amount Cornell contributes toward coverage, less the amount Cornell contributes for single coverage. The value is added in to your gross income biweekly. The tax implications vary by individual and you may need to seek the advice of your tax advisor.
If you are currently enrolled in individual plus child(ren) coverage, and are adding your same-sex partner to your coverage, your imputed income is calculated on the value of the university's contribution for single coverage.
Your additional contributions for providing benefit coverage to your same-sex partner is the same as that charged for a spouse. These amounts are deducted from your pay check on an after-tax basis.
Individual plus spouse/same-sex partner additional cost for 2008
|
24 Pays
|
26 Pays
|
|
$78.14
|
$72.13
|
Individual plus spouse/same-sex partner plus child(ren) additional cost for 2008
|
24 Pays
|
26 Pays
|
|
$111.93
|
$103.32
|
The cost of individual plus child(ren) coverage for your same-sex partner must be paid on an after-tax basis and cannot be deducted from your paycheck.
Types of Coverage Available
- individual coverage: covers the faculty or staff member only;
- individual plus child(ren) coverage: covers the faculty or staff member and his/her child or children;
- individual plus spouse/same-sex partner and child(ren) coverage: covers the faculty or staff member, his/her spouse or same-sex partner, and their child or children;
- dual eligibility.
Dual eligibility is a category available to an endowed staff or faculty member with dependent children whose spouse or same-sex partner is also a benefits-eligible staff or faculty member in an endowed unit of Cornell University. Only one employee enrolls for coverage and that employee covers all dependents, including the working spouse or same-sex partner. If you are covered within the dual-eligibility category, you must be sure to notify Benefit Services if you or your spouse or same-sex partner leave the employment of an endowed unit at Cornell. It is the responsibility of the employee to sign up for the dual eligibility rate.
It is not possible for dual-eligibility employees to cover each other
or to both cover dependent children within the endowed health care program.
Enrollment
Welcome to Cornell (WTC) sessions are scheduled for faculty and staff
upon initial employment at Cornell. The sessions are presented in a group
setting and are designed to explain the benefits available to university
employees. Each faculty and staff member are given enrollment materials
to complete, which includes enrollment in the health care program.
You have 60 days from your date of hire to enroll for health care coverage by completing the enrollment materials and returning them to Benefit Services. You will have the opportunity to change your coverage during the fall annual enrollment for coverage effective the following January 1.
Identification Cards
In approximately 14 days after you initially enroll, you should receive
your health care identification card at your home address. Members will
receive two ID cards listing their covered family members. You need to
show it to your health care provider so that your claims can be properly
handled. If you need additional cards, call HealthNow at (888) 995-3095.
Coverage Begins
Coverage starts for you when you begin employment, provided you are actively
at work on that date. If you are disabled, or not actively at work on
the date your coverage would be effective, your coverage begins after
one complete day of active employment.
Late Enrollment
A faculty or staff member who initially waives coverage and wishes to
enroll at a later date must wait until the annual enrollment in the fall
to enroll for coverage effective the following January 1. The exception
to this would be if the faculty or staff member had a family status change.
Coverage Changes: Annual Enrollment and Family Status Changes
Annual Enrollment
All eligible faculty and staff (including those who previously waived
coverage) have the opportunity to enroll once a year during the annual
enrollment period. Each employee receives a packet of information at his
or her home address and must return completed materials to Benefit Services
by the Open Enrollment deadline.
New coverage selected during the annual enrollment period is effective the following January as long as no one seeking coverage is hospitalized on that date. If a member of your family is hospitalized, coverage is delayed for that individual until he or she is released from the hospital.
Family Status Changes
It also is possible to add or drop coverage for yourself or your family
members ONLY if you experience one of the following family status changes
and contact Benefit Services within 60 days of any of the following events:
- marriage or divorce
- birth or adoption (effective date placed for adoption) of a child
- death of a spouse or child
- termination or commencement of your (or your spouse's) employment
- your spouse involuntarily loses eligibility for employer-provided health coverage or your spouse involuntarily gains coverage (e.g., your spouse's employer changes health coverage significantly or the eligibility requirements of the employer-provided health plan change to allow your spouse to be eligible for coverage)
- enrollment, graduation or termination of full-time (defined as 12 credit hours) student status
- qualifying for Medicare by you or your dependents
- family medical leave
Section 125, the Internal Revenue Code and related regulations which govern certain aspects of the plan's operation prohibit employees from making a change in coverage during the year unless one of the family status changes outlined above occurs. Of course, you can always change your coverage election during the annual enrollment period each November. Changes made during the annual enrollment period are effective January 1 of the following year. Our plan is administered in this manner to comply with IRS regulations.
To add or drop coverage you need to complete an enrollment form (available in 130 Day Hall) and return it to Benefit Services within 60 days of the status change. Changes not made within 60 days must wait until the annual enrollment period.
Adding Coverage for Newborns
If you have individual or individual plus spouse/same-sex coverage at
the time your child is born or adopted, you have 60 days to contact Benefit
Services to add that child to your medical coverage and to change to individual
plus child(ren) or individual plus spouse/same-sex partner plus child(ren)
coverage (complete a HealthNow Enrollment Form). Keep in mind that the
faster you add the child to your plan, the faster you will receive updated
ID cards and have claims processed without delays. HealthNow will
produce new ID cards in about 14 days following notification to Benefit
Services. You will need to present the card to your child's doctor
at the time your child needs follow-up care.
A faculty or staff member with individual plus spouse/ same-sex partner plus child(ren) coverage must also contact Benefit Services and complete a HealthNow Plan enrollment form indicating "change" to add a new child (within 60 days). You need to add your new child so that health claims for your child can be processed without delay. HealthNow will produce an ID card updating the covered dependent information in about 14 days.
Failure to add the newborn or adopted child within 60 days of birth or adoption will result in not being able to add the child to the Plan until the annual open enrollment period in November for coverage effective the following January 1.
Cost of Coverage
In most cases, your share of the cost of health insurance coverage is
deducted on a pre-tax basis directly from your paycheck. The cost of coverage
depends on whether you enroll in individual, individual plus spouse/same-sex
partner, individual plus child(ren), or individual plus spouse/same-sex
partner plus child(ren). In certain situations faculty and staff pay the
full cost of coverage (e.g., university leaves and statutory postdoctoral
fellows).
The cost, including the annual deductible and out-of-pocket maximum, is subject to change annually and depends in part on the claims experience of Cornell's faculty and staff and their families during the preceding year.
The HealthNow Plan premiums for 2008 are listed below:
| Type of Coverage | Biweekly | Semimonthly |
| Individual | $18.02 | $19.52 |
| Individual plus child(ren) | $81.18 | $87.95 |
| Individual plus spouse/ same-sex partner | $90.15 | $97.66 |
| Individual plus spouse/ same-sex partner plus (child)ren | $121.34 | $131.45 |
| Individual plus spouse/ same-sex partner working at Cornell (dual spouse*) plus child(ren) | $63.10 | $68.35 |
Health Coverage
The HealthNow Plan at Cornell is a managed care system for delivering
cost-effective quality care to patients. By enrolling in the HealthNow
Plan and using its network of health care providers:
- you pay no annual deductible
- you pay only $12 for an office visit
- you have better coverage for routine and preventative care
- you submit no claim forms
- you do not need to precertify hospital stays
Working within the Network
Central to any managed care system are "networks" of physicians,
hospitals, and other health care facilities and providers. They become
part of a managed care network by meeting the quality standards and other
requirements of the organization (in this case, HealthNow's) that is setting
up the network and will monitor the quality of care provided.
As part of the network, the health care providers agree to negotiated rates and specific member service standards. In return, their participation in a managed care network ensures them more predictable numbers of patients.
Two Levels of Benefits
In-Network (Preferred) Benefits
Each time you visit your physician, you pay a $12 copay. You do NOT have
to meet an annual deductible if you seek care from a participating provider.
Most other expenses are covered at 90% if you stay within the network. The most you will have to pay out of your own pocket each year if you stay within the network is $1,500 for an individual and $3,000 for a family, in addition to any copays such as office visits.
Out-of-Network (Non-preferred) Benefits
If you seek care from a non-participating provider, you will be required
to meet a $300 deductible and to pay 30% of the remaining expenses (subject
to the reasonable and customary allowance). The most you will be required
to pay out of your pocket for out-of-network services, in addition to
any emergency room copays, will be $2,500 each year for an individual
and $5,000 for a family.
Wellness and Preventive Care
After a $12 copay, the HealthNow Plan pays in-network benefits at 100%
of charges for the following medically necessary services:
- office visits, except mental health
- one routine physical examination per year for children age 2 up to age 19; one exam every 24 months for ages 19 and over
- well-baby care for children birth to age 2
- routine (self-referred) gynecological exams, one every calendar year
- routine eye exam, one every 24 months
- hearing exam, one every 24 months
- Hearing aid equipment:
Adults and children age 13 and older at 90% up to $1,500 per hearing aid per ear, once every four years.
Children age 12 and under reimbursed at 90% up to $1,500 per hearing aid per ear, once every two years.
The Plan pays in-network levels of up to 90% (100% after the out-of-pocket maximum is reached) of charges for the following medically necessary services and supplies:
- mammography examinations (includes one routine screening per calendar year).
- part-time or intermittent nursing care by or under the supervision of a registered nurse, and could also include physical, occupational or speech therapy if prescribed by a physician. In addition, eligible expenses for home health aide services, necessary medical equipment and other supplies that are medically necessary and that require a prescription by a physician will be covered
- diagnostic expenses, including costs for x-rays and laboratory tests as well as physician's fees for interpretation, except when these are performed in the physician's office, in which case the $10 copay applies.
- maternity expenses are covered the same way that expenses for any illness or injury are covered. Charges, including those for a birthing center and certified nurse midwife, are covered when incurred. The baby's room and board charges are considered part of the baby's expenses and credited against the baby's out-of-pocket maximum.
Emergencies
Medical emergencies are those whose symptoms could be perceived as life-threatening
or as causing serious harm if not treated quickly.
For medical emergencies that require immediate care, network coverage levels are provided whether you seek emergency medical help from in-network or out-of-network providers. The important thing to do in an emergency is to receive care for that emergency. After the emergency is over, and care has been given, then you or someone close to you should contact your primary care physician, so that the primary care physician can update his or her records and begin to manage your care at that point.
Out-of-pocket Maximum
The out-of-pocket maximum is the most you will have to pay for eligible
medical expenses in a calendar year. When your share of expenses, excluding
your $12 copay, reaches $1,500 for an individual, or $3,000 for your entire
family, the plan pays $100% of eligible covered expenses for the rest
of the calendar year for in-network expenses.
The following charges are not eligible to be credited toward the out-of-pocket maximum: amounts you are penalized for failure to comply with the program's cost containment features; copays, amounts above and beyond reasonable and customary charges; items not covered under the plan.
If you receive care that is non-preferred (out-of-network), you will be required to meet the non-preferred deductible before HealthNow starts to reimburse you. Those services are subject to the non-preferred benefits, those services cannot be applied against the preferred (network) out-of-pocket maximums.
Reasonable and Customary (R&C)
In joining the HealthNow network, physicians and health care facilities
have agreed to charge negotiated rates. They cannot balance bill. Your
out-of-pocket costs will be 10% of the total charge.
It is standard practice for insurance companies to set, within defined geographic areas, reasonable and customary limits for common medical procedures. HealthNow obtains R&C information from the Health Insurance Association of America. If you seek care out-of-network, HealthNow will reimburse at 70% after the deductible subject to R&C. You may actually pay more than the $3,000 individual out-of-pocket maximum.
Centers of Excellence Program
HealthNow’s Centers of Excellence Program recognizes how difficult
it is for a patient/family who may be facing a complex medical procedure
or transplant. As a patient needs arise for highly specialized procedures,
certified case managers will work with the patient, family and physician
in determining the most appropriate facility and physician as well as
providing continuity of care. HealthNow will provide access to care through
our expanding network of healthcare providers identified as providing
successful clinical outcomes.
Out of Area Policy
For Members on Sabbatical and/or Members/Dependents Out of the
Area
If you and/or any covered dependents will be out of the area, you must notify the HealthNow customer care team at (888) 995-3095 or TDD (877) 209-6405 before seeking treatment, except in the case of a life threatening emergency. This notification will allow HealthNow to provide you and/or your covered dependents with a list of participating providers who offer quality healthcare services in the geographic area where you are seeking medical care. By utilizing the services of these providers, who are part of the Beech Street network, you and/or your covered dependents can be assured to receive the highest level of care at the in-network benefit level.
Beech Street is a national provider network that has contracted with HealthNow to provide you or your dependents with medical services while out of the area.
When you have contacted HealthNow for a list of participating Beech Street providers in your area, the following benefits will apply:
- If you receive medical care from a Beech Street participating provider, you will be covered at the in-network benefit level of a $12 copay of or 90% as outlined in the HealthNow Plan summary of benefits
- If you receive medical care from a non-participating provider, you will be covered at the out-of network benefit level of 70% as outlined in the HealthNow Plan summary of benefits. As always, life threatening emergency care will be covered at the in-network benefit level.
- If you receive medical care from a non-participating provider, and did so because there was no Beech Street participating provider available within a 30 mile radius, your claim(s) will be retroactive adjusted to the $12 copay or 90% in-network benefit level. Please contact HealthNow customer care team in the event you have sought medical care under these circumstances.
If you receive care from a Beech Street provider, your claims will be filed by Beech Street. If you receive care from a provider who does not participate with Beech Street, you will be responsible for payment of care at the time services are rendered. You will then need to submit your claims through the HealthNow customer care team.
For medical care received out of the area, it is highly recommended that your local primary care provider be notified so he/she may update your medical records and continue the management of your care when you return.
Please remember, in all cases, precertification is still required for inpatient services and select outpatient procedures. Please refer your summary plan document for a listing of services and procedures that require precertification or call HealthNow at (888) 995-3095. When residing out of the area, it is the members responsibility for precertification for both inpatient and select outpatient procedures.
If you need help identifying participating providers in your area, call HealthNow’s customer care team at (888) 995-3095 or TDD (877) 209-6405. They are available Monday through Friday from 7:00 am to 6:00 pm.
Three-Tier Prescription Drug Plan Administered by Medco $5/$20/$40
Prescription drugs are covered through Medco.
Hospital Expenses
Eligible hospital expenses are reimbursed at 90% at a participating hospital.
If out of network, reimbursement (after deductible) is at 70% subject
to R&C, until you have paid $3,000, then reimbursement is at 100%.
Charges eligible for reimbursement include a semi-private room and board charges, intensive care unit charges and additional medically necessary services and supplies.
Surgical Expenses
Inpatient and outpatient surgical expenses are eligible for reimbursement
at 90% at the in-network level except when the surgery is performed at
the physician's office in which case a $12 copay is required. Covered
expenses include: pre-operative and aftercare for covered surgical procedure
required for treatment of diseases, injuries, fractures and dislocations.
If you will be hospitalized for inpatient surgery, (except for cases of medical emergency), you must use a participating provider/hospital to receive the in-network level of benefits. Otherwise, you will receive the out-of-network benefit level of 70%, and you must precertify in advance by calling HealthNow at (888) 995-3095 to avoid a precertification penalty.
Home Health Care
The HealthNow Plan pays 100% up to a maximum of 300 visits per calendar
year (in-network) of covered charges provided under an approved home health
care plan by an approved home health care agency. The care provided must
be in lieu of an inpatient hospital confinement. Previous hospitalization
is not required. Each four-hour period of home health aide services is
considered one visit. Each visit by a nurse or a therapist is considered
one visit.
Covered charges include a part-time or intermittent nursing care by or under the supervision of a registered nurse, and could also include physical, occupational or speech therapy if prescribed by a physician. Eligible expenses for home health aide services, necessary medical equipment and other supplies that are medically necessary and which require a prescription by a physician will be covered. Custodial care is not covered.
Skilled Nursing Facilities
The HealthNow Plan covers treatment provided in an approved skilled nursing
facility at 90% (in network). To qualify for this coverage you must have
been hospitalized for at least three days, then confined in a skilled
nursing facility within 14 days of discharge from the hospital. Confinement
must be medically necessary as certified by your attending physician.
Custodial care, services and supplies furnished mainly to assist a person in maintaining the skills of daily living are not eligible for reimbursement under this or any other provision of the health care program.
Hospice Care
A hospice is a public or private organization that provides care and services
for terminally ill patients. A person is considered terminally ill if
he or she is expected to live six months or less.
Inpatient hospice benefits are payable at 100% for terminally ill patients when provided as part of a physician's written, approved hospice care program. Covered charges include treatment for pain control and other acute and chronic symptom management.
Hospice care can also be provided in an outpatient setting. Services provided by a hospice care agency are eligible for reimbursement at 100%. Charges eligible for reimbursement include up to eight hours daily of part-time intermittent nursing care provided by an RN or LPN or up to eight hours daily of part-time or intermittent home health aide services. Medical supplies, drugs, and medicines prescribed by your physician, medical social services under the direction of your physician, charges for therapy provided by physical or occupational therapists or charges by physicians for consultation or case management services are also covered.
Oral Surgery
The oral surgery benefit pertains to certain periodontal surgeries, accidental
injury to the teeth and surgical extractions. If your dentist recommends
oral surgery, you need to see an oral surgeon that participates in HealthNow's
Network. Oral surgery is covered at the in-network level after the $12
copay. The oral surgeon will also need to review this before the work
is performed so that you are aware in advance which portion is covered
under the Plan.
Nutritional Counseling
Nutritional counseling is not typically covered by health care programs.
However, the Plan is designed to emphasize good primary and preventive
care, so it does provide limited coverage for nutritional counseling.
The Plan reimburses at 90% for one initial visit and up to three follow-up
visits.
Behavioral Health Benefits
ValueOptions administers benefits for the treatment of mental illness,
alcoholism and drug abuse for Cornell’s Endowed Plan. ValueOptions
is a leading provider of Managed Mental Health and Substance Abuse Programs.
They have been managing the behavioral needs of over 20 million members
associated with 50 Fortune 500 Firms, Government Agencies, small- and
mid-sized companies. Their national provider network includes more than
1,700 facilities and 40,000 licensed practitioners who are continuously
evaluated to determine their ability to help.
Inpatient Benefits
In order to receive in-network benefits, members must receive
care from a provider participating in ValueOptions Network. Inpatient
care must be pre-certified. To receive the in-network benefit level, you
must contact ValueOptions at (800) 895-2799 prior to receiving care. Failure
to meet medical necessity requirements may result in no coverage.
Inpatient mental health and substance abuse benefits are reimbursed at 90% up to 45 days per calendar year. No credit is given toward the medical out of pocket maximum. The inpatient calendar year maximum of 45 days is a combined limit for both mental health and substance abuse care received in-network and out-of-network. If you decide to seek care out-of-network, you will be reimbursed at 70% of reasonable and customary as determined by ValueOptions (up to 45 days per calendar year combined total for in- and out-of-network visits).
Outpatient Benefits
In-network, outpatient mental health and substance abuse benefits
are reimbursed at 100% after a $12 copay (up to 50 visits per calendar
year combined total for in- and out-of-network visits). Out-of-network,
outpatient mental health and substance abuse benefits are reimbursed at
70% of reasonable and customary (up to 50 visits per calendar year combined
total for In and Out of Network visits). The outpatient calendar year
maximum of 50 days is a combined limit for both mental health and substance
abuse care received in-network and out-of-network.
All mental health and substance abuse benefits are reviewed for medical necessity. This means that the treatment and services are consistent with symptoms for proper diagnosis for the illness, disease or condition as determined by ValueOptions. In addition, ValueOptions will authorize the appropriate level of care that can be safely provided for the diagnosed condition in accordance with generally accepted psychiatric and mental health practices and the professional and technical standards adopted by ValueOptions.
If you seek care out-of-network, it is your responsibility to notify the provider of the need to confirm medical necessity with ValueOptions. You also need to be sure to tell your out-of-network provider that they must submit an Outpatient Treatment Report (OTR) to ValueOptions by the 10th visit in order for ValueOptions to authorize medically necessary outpatient care that may be required beyond the initial visits. If the OTR is not received by ValueOptions, ValueOptions may not authorize any additional benefits.
Emergency Care
In an emergency, ValueOptions will arrange for a psychiatrist
to meet you at the emergency room or direct you to a local facility for
treatment. If you cannot call, or are in a life-threatening situation,
go directly to an emergency room and notify ValueOptions within 72 hours
of the treatment. If you do not call within 72 hours, benefits will be
paid only for services received after you call. If you do not call
at all, you will not receive any plan benefits.
Filing Claims
ValueOptions processes claims for all mental health and substance
abuse services. If you receive care from an in-network provider, they
are responsible for submitting all claims to ValueOptions. If you receive
care from an out-of network provider, you will need to file a claim to
receive benefits by completing a standard HCFA claim form (available from
your provider). Claims should be sent within 12 months of receiving treatment
to:
ValueOptions
PO Box 1347
Latham, NY 12110-8847
If members have questions concerning benefits, claim inquires or the status of providers, members should call (800) 895-2799 and a customer service representative can help answer questions.
Other Medical Services and Supplies
- private nursing charges by a registered or licensed practical nurse
- doctor's office visits for treatment of illness or injury
- diagnostic expenses, including costs for x-rays and laboratory tests as well as physician's fees for interpretation
- maternity expenses are covered the same way that expenses for any illness or injury are covered. Charges, including those for a birthing center and certified nurse midwife, are covered when incurred. The baby's room and board charges are included in the mother's charges.
- services provided by a licensed chiropractor, subject to medical necessity review
- allergy serums
- services provided by a licensed podiatrist for diagnosis, treatment and surgery
- speech therapy when performed by a qualified speech therapist to restore speech to an individual who has lost an existing speech function as the result of a disease or injury
- treatment provided by a physiotherapist or an occupational therapist
- artificially assisted fertilization reimbursed up to $20,000 lifetime maximum
- miscellaneous services and supplies including the following when they are considered necessary medical care or treatment: x-rays, radium and isotope therapy; anesthetics and their administration; medical and surgical equipment rental; casts, splints, trusses, braces, crutches and surgical dressings; blood and blood plasma; artificial limbs and eyes; and ambulance services
Exclusions and Limitations
All medical treatment, services and supplies must be necessary and prescribed
by a legally licensed physician. However, certain treatments or services
will not be considered. Reimbursement is not provided for the following
expenses:
- charges related to a service, supply or treatment that is not generally accepted by the medical profession, or that is deemed to be experimental or for purposes of research
- expenses for treatment neither the covered individual or any other person has a legal obligation to pay
- charges for custodial care, which is rendered to a patient primarily for the purpose of meeting personal needs to support the essentials of daily living
- treatment of temporomandibular joint dysfunction (TMJ), except for diagnostic purposes or in regard to medically necessary oral surgery. Examples of services/supplies not-covered are therapy, occlusal equibration, or rehabilitation orthodontics such as charges for appliances used to alter occlusion and/or reposition the lower jaw, whether or not the purpose of such service or supply is to relieve pain
- dental work, unless it’s required because of an accident (within 12 months) to natural healthy teeth in good repair
- occupational illness or injuries which are covered by Worker's Compensation
- expenses incurred on account of war, or for services, supplies and treatment provided or covered under any governmental plan or law
- services in connection with cosmetic surgery except for reconstructive surgery due to disease or injury; other surgery for the prompt repair of an injury that occurs while the person is covered; or a congenital abnormality that causes a functional defect in a dependent child
- charges for education, special education or job training, unless given in a facility that also is providing medical or psychiatric treatment
- eye glasses, except for temporary and/or initial permanent corrective lenses needed following a cataract operation
- charges for acupuncture therapy, except for acupuncture performed by a physician as a form of anesthesia in connection with surgery that is covered under this program.
Coordination of Benefits (COB)
The Plan has a maintenance of benefits provision that provides payment
up to the normal reimbursement level under the Plan. When you or your
covered family member has other group health care benefits available or
if payment is made under a "no-fault" auto insurance policy,
the maintenance of benefits provision takes effect.
This means that the combined payment from both sources will not exceed the amount the Plan pays when there is no coordination with another plan. Under most circumstances, your combined reimbursement will total 90% and you will still have responsibility for the 10% copay until your out-of-pocket maximum has been reached. The three-tier prescription drug plan is a card program and is excluded from the maintenance of benefits provision.
Coordination with No-Fault Auto Insurance
In the case of a payment under the New York's "no-fault" auto
insurance, the first $50,000 is paid by New York State. Any charges remaining
are reimbursed, after deductible, at 90% until the out-of-pocket maximum
is reached.
Subrogation Provision
This provision prevents faculty/staff and covered family members from
being reimbursed for medical bills both from the Plan and from a third
party insurance company, in effect receiving a duplicate reimbursement.
For example, a subrogation right might exist when the Plan has paid medical expenses for injuries and faculty/staff member suffered while helping a neighbor repair his or her roof. If the injured faculty/staff member receives a payment form a third party for medical expenses incurred as a result of the fall (for example, the neighbor's homeowner's policy), the Plan is entitled to be reimbursed for all or part of the costs covered through Cornell's health care plan. In order to review possible subrogation situations, claims will be pended by HealthNow until details are received explaining the nature of the accident.
Order and Priority of Benefits
Under the COB provisions, you file your claim with the primary carrier
first and then send copies of the same bills and your Explanation of Benefits
to the secondary carrier for consideration.
A plan without coordination of benefits always pays first. If all plans have COB provisions, the order of payment is determined by the following:
- the plan covering the person directly, rather than as a dependent, pays its benefits first
- in the case of dependent children, the plan of the parent whose birthday occurs first in the calendar year will pay benefits first
- in the case of a divorce or separation, the plan that covers the parent with financial responsibility for health care expenses, a qualified medical support order (QMCSO), or custody pays benefits first
- the plan that has covered the person for the longer period of time shall be primary except if a retiree or laid-off worker goes to work for another employer. The plan of the current employer will pay benefits before the plan covering the individual (and family) as a retiree or laid-off employee.
If you are covered by more than one group health insurance plan and need assistance determining which plan should receive your bills first, call HealthNow at (888) 995-3095.
Continuation and Termination of Benefits
When Coverage Ends
Unless you provide notification that you would like to continue health
coverage, your current coverage will end at the end of the pay period
in which you receive your last paycheck.
Continuing Coverage
Faculty and staff and/or their eligible family members who are covered
under the Plan may continue medical coverage should one of the following
situations occur (provided coverage is in effect on the date the event
occurs):
- family medical leave
- death or total disability
- divorce or legal separation
- layoff of a covered employee
- retirement prior to eligibility for Medicare
- veterans called to active duty
Family Medical Leave
Family Medical Leave entitles eligible faculty and staff to unpaid time
away from work, up to total of 12 weeks during the fiscal year (July 1
- June 30). This is in accordance with the Family and Medical Leave Act
(FMLA) of 1993. Contact Medical Leaves Administration or review the Human
Resource Policy 6.9 Time Away from Work and related guidelines for full
details about FMLA.
You may continue your existing health insurance coverage during an unpaid FMLA, (no use of accrued sick or vacation) and you will be billed by Records Administration. If you decide to terminate your health insurance coverage either at the start or during your FMLA, when you return from the leave, you have the right to have your health insurance reinstated, within 60 days, on the same terms as prior to the leave.
Spouse, Same-Sex Partner and Dependent Coverage After Your Death
In the event that a covered employee or retiree dies, the surviving spouse/same-sex
partner and any eligible covered dependent children may continue the health
care plan until the surviving spouse remarries, the same-sex partner indicates
that the exclusiveness of the former relationship has been made void,
and/or the dependent children no longer qualify under the program definitions.
The university contribution will continue and the surviving spouse or
same-sex partner will be billed for any required employee or retiree contribution.
Short Term Disability
A covered staff member who qualifies for short term disability benefits
can continue the coverage in effect at the time the disability occurs
until the disability ends. The university contribution will continue during
the period of disability and the staff member will continue to have the
health insurance premium deducted from the paycheck.
Total Disability
A covered faculty or staff member who qualifies for long term disability
benefits can continue the coverage in effect at the time the disability
occurs until the period of disability ends. The university contribution
will continue during the period of disability and the faculty or staff
member will be billed for any required contribution.
Worker's Compensation
As a regular university faculty or staff member, you are eligible to continue
certain benefits while you receive Worker's Compensation benefits. There
is no change in your benefits as long as you continue to receive a Cornell
paycheck. Normal health insurance deductions will be taken out of each
check. However, once you are no longer receiving a paycheck from Cornell,
endowed faculty and staff are billed on a quarterly basis for the employee
cost of health insurance.
The university contribution will continue during the period of disability and the faculty or staff member will be billed for any required contribution.
Divorce or Legal Separation
If you or your spouse decide to legally separate, you (and any eligible
dependents) can continue coverage. However, your ex-spouse will no longer
be eligible to continue coverage under your plan. Your ex-spouse will
need to call Benefit Services at (607) 255-3936 to request a COBRA application
to continue coverage within 60 days of the event or legal separation.
The ex-spouse will be billed monthly, in advance, for up to 36 months.
Qualified Medical Child Support Order
As a general rule, your plan benefits may not be assigned to another person.
However, an exception exists in the case of a "qualified medical
child support order". A qualified medical child support order is
a court-ordered judgment, decree, order or property settlement agreement
in connection with state domestic relations law that either:
- creates or extends the rights of an "alternate recipient" to participate in a group health plan, including this plan, or
- enforces certain laws relating to medical child support.
An "alternate recipient" is any child of a participant who is recognized by a medical child support order as having a right to enrollment under a participant's group health plan. A medical child support order must satisfy certain specific conditions to be qualified. The plan administrator will notify you if he or she receives a medical child support order that applies to you. You will also be notified of the plan's procedures for determining whether the medical child support order is qualified. The cost of our coverage depends on whether or not you elect individual or family coverage.
Coverage During Layoff
Faculty or staff members who are no longer working because of a layoff
or reduction in work force will continue this coverage under COBRA. Completion
of a COBRA application is required. The University contribution toward
the cost of health coverage will continue for up to 12 months. If coverage
is elected, you will be billed for the employee portion of the cost of
your health plan. At the end of 12 months, you will be billed the normal
COBRA contribution rate for the remainder of your COBRA eligibility period.
Note: Aetna Inc. is the COBRA administrator and even though you will be
billed by Aetna Inc., your coverage will continue through HealthNow.
Position Leave
Employee's existing health insurance coverage will be maintained during
the leave period provided they continue to pay both their share and the
university's share of premiums (full cost).
University Leave
Staff members who voluntarily resign their positions and are granted a
University Leave are eligible to continue this plan under COBRA.
Employees will need to obtain a COBRA application from Benefit Services,
complete it and return it to Aetna Inc.'s COBRA Unit within 60 days of
their University Leave date. Aetna Inc. administers the COBRA billing
but your coverage will remain through HealthNow.
Temporary Coverage Under COBRA
COBRA (Consolidated Omnibus Budget Reconciliation Act) is federal legislation
which requires that employers make continuing health coverage available
to employees who are no longer eligible for coverage based on the following
situations:
- termination of employment for reasons other than gross misconduct
- reduction in work hours resulting in loss of eligibility for health coverage
- a dependent child no longer meets the program's eligibility requirements.
The duration of COBRA coverage depends on the particular event that causes you or an eligible member of your family to lose coverage.
18- Month COBRA Eligibility
If your employment terminates, your work hours are reduced or you are
on a leave of absence, you and your covered dependents have the opportunity
to subscribe for continuation of health coverage at group rates, for up
to 18 months. You will automatically be notified of your eligibility to
temporarily continue health coverage by the university. If you do elect
to subscribe for coverage, you will be billed month, in advance for the
full cost of this coverage (plus an additional 2% administrative fee).
36-Month COBRA Eligibility
If you dependent loses eligibility for health coverage because he/she
no longer meets the health program's definition of an eligible dependent
or if you are divorced and your ex-spouse wishes to continue prior coverage,
Benefit Services must be contacted within 60 days of the event. You will
be sent a continuation application to be completed and returned to Benefits
Services. The cost of COBRA coverage will be billed monthly, in advance,
for up to 36 months by the Aetna Inc. COBRA Direct Billing Unit.
It is your responsibility to initiate this contact with Benefit Services within 60 days. Employees are responsible for paying the full cost of COBRA coverage (plus and additional 2% administrative charge). Failure to pay these charges within 30 days of the billing date will result in immediate termination of coverage.
Sabbatical Leaves
Coverage continues provided you continue to pay the required
premium, which continues to be deducted from your paycheck.
Coverage Upon Retirement
Your coverage under the Cornell Health Care Program can be continue into
retirement if you are at least age 55 when you retire and have at least
10 years of benefits-eligible service with Cornell University. Important:
If you decide not to continue your health insurance at any time and cancel
your coverage, you will not be able to re-enroll at a later date.
If you are not yet age 65 when you retire and are therefore, not eligible for Medicare, you have the opportunity to continue coverage under the health care program that is available to active employees. If you are covering a spouse/same-sex partner under the plan who is retired and age 65 or older, they must enroll in Medicare Parts A&B. This also applies if your spouse/same-sex partner has been receiving Social Security Disability benefits and is eligible for Medicare. As a retiree, coverage under the 80/20 Plan has a limitation in that private duty nursing is covered at 50% of eligible charges. Upon attainment of age 65, you will automatically be transferred to Cornell's 80/20 Plan for Retirees.
If you are 65 or older when you retire and are eligible for Medicare, you will receive coverage under the 80/20 Plan for Retirees. This coverage is described in the section called 80/20 Plan for Retirees.
An employee who retires and has not met the eligibility requirements for retiree medical coverage may be eligible to continue coverage under the COBRA provisions. If you retire before you turn 65 and are not eligible for Medicare, you can continue coverage for up to 18 months or until you are eligible for Medicare (whichever occurs first). Your family members also have the opportunity to continue health coverage for a period not to exceed 36 months from the date you retire or become eligible for Medicare.
Filing for Medical Claims
If you need help filing claims or have questions, you can call HealthNow
at (888) 995-3095 or TDD (877) 209-6405 and a Customer Care Team member
will be happy to help you.
Under the HealthNow Plan, whenever you pay a copay, you do not need to complete a claim form. When you receive services with in the network, the providers are responsible for filing claims to HealthNow. Only in certain situations are you required to submit a claim, for example, lab work performed outside the physician's office. You will need to file a claim directly with HealthNow.
Whenever you seek care outside of the HealthNow Network, you will be responsible for filing a claim for reimbursement. When you are ready to submit a claim for payment, complete the first page of the claim form and then attach a copy of your itemized bill, or have your physician complete the back page of the claim form. Send it to:
HealthNow
PO Box80
Buffalo, New York 14240
If your claim involves coordination of benefits with another insurance company, you must also include a copy of the explanation of benefits provided by the other company (including Medicare). Claims must be filed within 2 years from the date of service.
Medical benefits for any covered individual may be assigned to the hospital, doctor or other health care provider. When benefits are assigned, payment will be made directly to the health care providers.