EVENTOS Y RIESGOS EN LA PROVINCIA DE PICHINCHA
2. DESCRIPCIÓN DE LA PROVINCIA
2.4. RIESGOS POR DESASTRES NATURALES QUE SE PRESENTAN EN LA PROVINCIA DE PICHINCHA
2.5.2. Análisis de las Vulnerabilidades de la provincia de Pichincha.
1. Court Decree for One Parent to Maintain Financial Responsibility: The following chart is used to determine which plan
is primary, which plan is secondary, etc., when a court decree exists ordering one parent or the other (but not both) to maintain financial responsibility for the health care of the child:
FIRST, the plan of the parent who has financial responsibility.
SECOND, the plan of the Spouse of the parent (step-parent) with financial responsibility.
THIRD, the plan of the parent without financial responsibility.
FOURTH, the plan of the Spouse of the parent (step-parent) without financial responsibility.
If a determination cannot be made following the guidelines contained in this chart, then the rules listed at the top of this page under General Guidelines apply.
2. No Court Decree; or Court Decree for Both Parents to Share Financial Responsibility when One Parent Has Primary Custody: The following chart is used to determine which plan is primary, which plan is secondary, etc., if one parent has been
awarded primary custody of the child and a) a court order exists ordering both parents to have equal financial responsibility for the health care of the child: or b) no court order exists regarding such financial responsibility:
FIRST, the plan of the parent who has primary custody.
SECOND, the plan of the Spouse of the parent (step-parent) with primary custody.
THIRD, the plan of the parent without primary custody.
FOURTH, the plan of the Spouse of the parent (step-parent) without primary custody.
If a determination cannot be made following the guidelines contained in this chart, then the rules listed at the top of this page under General Guidelines apply.
3. Court Decree for Both Parents to Share Financial Responsibility when Joint Custody Has Been Awarded: If a court
order exists establishing that: a) both parents have been awarded joint custody of the child (regardless of which parent has physical custody); and b) the parents must maintain equal financial responsibility for the health care of the child, the plans are coordinated using the General Guidelines previously listed.
General Guidelines
FIRST, the plan covering the dependent the longest will be primary;
SECOND, the plan of the parent whose birthday falls earlier in the year;
The above rules shall apply until such time as the National Association of Insurance Commissioners (NAIC) establishes specific guidelines for married dependent children at which time the NAIC guidelines will be in effect.
If the Trust is the secondary insurance carrier, you or your Provider should submit your claims to both your primary carrier and the Trust. After the primary carrier has processed the claim, you (or your Provider) should submit a copy of the primary carrier’s Explanation of Benefits (EOB) to the Trust.
Claims must be received in the Trust office no later than twelve months following the date of service.
CLAIMS NOT RECEIVED IN THE TRUST OFFICE WITHIN TWELVE MONTHS OF THE DATE OF SERVICE WILL BE DENIED!!!
Exceptions for Plans of Divorced, Separated or Never-Married Parents
Married Dependent Children’s Coverage
How to File Claims When the Trust Coverage is Secondary
If the Retiree Health Plan processes a claim as the primary payer and it is later discovered that another insurance carrier should have been primary, the Trust will request a refund of any benefits paid from you and/or your Provider.
If my primary plan states I need a prior authorization for this service or I have to use one of their plan providers and I either do not get the prior authorization or I do not use one of their plan providers, will the Trust pay on these expenses?
No, the Trust will not consider these expenses as you did not follow the guidelines of your primary plan.
My spouse is primary, per the birthday rule, but my coverage through the Trust is better. What happens if I just give the doctor my Trust ID card?
If the Trust Plan processes your claim with the Trust as the primary payer and it is later discovers it was not the primary insurer, the Trust will request a refund of any benefits paid from you and/or your Primary insurer.
Occasionally, you or your Dependent(s) may receive services for Injuries caused by another person or entity. The plans will not provide benefits for expenses that are the liability of another party due to the commission of a negligent act. As a Trust participant, you are entitled and encouraged to access the Trust provider network for medical or dental services. The Trust will process your medical or dental expenses pending settlement of any claim you may have against another person. However, before any payment can be made, you must complete and sign a Third Party Liability Agreement and submit it to the Trust office. (If applicable, a police report must also be submitted to the Trust.) If you elect not to complete and sign the Third Party Liability Agreement, your claims will not be paid by the Trust.
By signing the Third Party Liability Agreement, you agree to the following terms and conditions:
▪ You will make a claim against the other person or entity before the Trust will process your medical or dental claims.
▪ The Trust has a subrogation provision which requires that the Trust be reimbursed for benefits paid to you or for you when you have a valid and collectible claim against either the person/business responsible for your or your Dependent’s Injuries (whether or not that person has automobile or homeowner’s/business liability insurance), or under the uninsured/underinsured motorists provision of your own automobile policy. This provision applies regardless of whether or not you have been made whole after your claim has been resolved.
▪ If Medical Payments Coverage (Medpay) is part of your automobile insurance policy, and/or part of any insurance policy of the driver of the vehicle or a pedestrian when you were injured, the Trust will not pay benefits for injuries you sustained in an accident as a driver, passenger, or pedestrian until any and all Medpay benefits from all applicable insurance policies have been exhausted and the Trust is furnished with written proof of payment by the insurance company(ies).
• Once Medical Payments Coverage (Medpay) is verified as part of your liability insurance policy, and/or part of any insurance policy of the other person or entity that caused your injuries (such as automobile, homeowners, business premises, commercial activities, etc.), the Trust will not pay benefits for injuries you sustained until any and all Medpay benefits from all applicable insurance policies have been exhausted and the Trust is furnished with written proof of payment by the insurance company(ies).
▪ If the award of damages or the settlement does not specify the portion applicable to medical or dental expenses, the Trust will consider the amount due from the responsible person to be applied to your medical or dental expenses first.
Errors in Payment
Coordination of Benefits
Frequently Asked Questions
▪ You must promptly reimburse the Trust for any payments received from the responsible person or entity for medical or dental expenses after deducting allowable attorney fees and court costs. If you fail to do so, the Trust will be authorized to deduct or offset the amount not reimbursed from any future benefits to which you may be entitled under the Plan.
By signing the Third Party Liability Agreement, you agree to the following terms and conditions:
▪ The Trust may file a Notice of Lien with you and/or your attorney, as well as any automobile or business insurance carrier, against any monetary recovery made in connection with another party’s liability. You must agree to authorize the filing of the Notice of Lien and agree to obtain the full and complete cooperation of attorneys or representatives in connection with the Trust’s efforts to obtain reimbursement under the Agreement.
▪ You must authorize health care Providers, insurance companies, employers, and attorneys to furnish the Trust with information regarding the treatment for all injuries.
If you do not want to enter into a Third Party Liability Agreement, the Trust benefits (if any) will not be paid until after you settle any claims with the person who caused your injuries. Payments from the Trust will then be reduced by any damages and/or settlement paid or owed by that person. If the award of damages or the settlement does not specify the portion applicable to medical or dental expenses, the Trust will consider the amount received to be applied to medical or dental expenses first.
ONCE YOU HAVE RECEIVED A SETTLEMENT, YOU MUST USE THAT SETTLEMENT AMOUNT TO PAY ALL FUTURE EXPENSES RELATED TO THE INJURIES CAUSED BY THE OTHER PARTY. IF THE FUTURE EXPENSES EXCEED THE SETTLEMENT AMOUNT, AFTER PAYMENT OF ATTORNEY’S FEES AND COSTS, IF ANY, YOU MUST PROVIDE ANY DOCUMENTATION REQUESTED BY THE TRUST BEFORE FUTURE INJURY-RELATED EXPENSES WILL BE CONSIDERED FOR PAYMENT BY THE TRUST.
Keep an eye out for this guy! He will warn you about potential
mistakes that could affect your eligibility or unnecessarily
increase your personal expense.
Introduction
177
Retiree PPO Medical Plan 177
Retiree Medicare Advantage Plan 177
Frequently Asked Questions 177
Definitions
177
Benefit Limitations/Maximums
179
Copayment/Coinsurance Maximums
180
Case Management
181
Prior Authorizations
182
Filing a Medical Claim
184
Acupuncture Services
185
Allergy Services
185
Ambulance Services
185
Covered Expenses 185 Limitations 185Anesthesia Services
186
Chemical Dependency Services
187
Chemotherapy & Radiation Services
188
Chiropractic Services
188
Concierge Care
188
Cosmetic Services
189
Diabetic & Nutritional Education
190
Diabetic Education Classes 190
Nutritional Consultations 190
Diagnostic Testing
191
Dialysis & Related Services
193
Durable Medical Equipment & Supplies
193
Definition 193
Limitations 194
Frequently Asked Questions 195