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FAQ/Coverage

Coverage

1. How do I file a claim?

When you use a network hospital or doctor, no claim forms are required. Just show your MILA CIGNA HealthCare ID card so the provider knows to bill us.

If you do receive a bill from a network provider, review the bill to make sure it is not an "information only" statement. Most providers will send you a statement showing the total amount due and informing you they billed the health plan. If it is a bill, ask the provider if the bill has been submitted to MILA CIGNA HealthCare. Most providers use systems-generated billing where their computer automatically sends out the bill. Providers belong to many different health plans and may not have billed us correctly.

Out-of-network claims require a claim form. Claim forms can be obtained from your Local Port Administrators offices. Fill out the MILA claim form and send it to the claims address listed on the form or on the back of your MILA CIGNA HealthCare ID card.

2. If I have a pre-existing condition, what do I do?

A pre-existing condition is an illness or condition for which you have been diagnosed; received treatment or incurred expenses before you became a participant of the MILA CIGNA HealthCare. You will be covered for treatment you receive for such conditions while you are covered under the Plan.

3. What is the Open Access Plan?

The Open Access Plan is a network-based, managed care plan that allows the member to coverage any health care provider. However, if care is received from participating in-network provider, there are generally higher benefits coverage, lower out-of-pocket expenses, and no claims forms.

4. What is an HMO?

An HMO (Health Maintenance Organization) is a type of health plan in which your primary care physician (PCP) manages your care. Typically, an HMO provides care only through its participating physicians. An HMO can differ from traditional insurance programs by focusing on wellness and disease prevention, rather than simple reimbursement after illness or injury strikes. The HMO approach makes it easier for physicians to do what they do best -- safeguard the health of their patients. However, an HMO restricts your choice of physician to those in its network. MILA Managed Health Care Trust Fund is not an HMO.

5. Why am I not being reimbursed from my Medicare Part B Premium? I am Medicare eligible

In order to receive Medicare Part B premium reimbursement, you must join a Medicare+Choice HMO with prescription drug benefits. After joining the HMO, you must show proof of your enrollment. Then, MILA will reimburse your Medicare Part B premium on a quarterly basis.

6. Why doesn't MILA continue to pay my Medicare+Choice HMO?

As of December 31, 1999, MILA canceled its contracts with the various HMO’s that were designated as the MILA approved HMO’s. Individuals who wish to continue with a Medicare+Choice HMO can do so. Please note that all HMO premiums will be billed to you. If you joined a Medicare+Choice HMO with prescription drug benefits effective January 1, 2000, MILA will reimburse your Medicare Part B premium. (Proof required ).

7. Who will provide us with Dental and Vision coverage?

Under the MILA National Choice Plan, dental and vision is not covered. Please check with your local Port Administrator for these benefits.

8. If I am a pensioner on Reduced Benefits, will I be covered under the MILA plan?

Pensioners covered under a local Port benefit plan in effect on 9/30/96, which provided lower benefits than the plan for active members will continue to be covered in that plan through the local Port. The Plan has been sponsored by MILA since 1/1/2000. Please see your local Port Administrator for more information. When the pensioner or his dependent become eligible for Medicare benefits, that person will be eligible for coverage under MILA’s supplement to Medicare provided that the pensioner is entitled to continued benefit.

9. If I am on Clinic Only Benefits (NY/NJ), will I be covered under the MILA plan?

See the answer provided for pensioners on reduced benefits, above. For more information, please see your local Port Administrator.

10. If I am Medicare Eligible, can I get a MILA CIGNA Provider Directory Book?

If you are Medicare eligible, you do not need a MILA CIGNA book. You can go to any doctor or any hospital that accepts Medicare.

11. What if I move?

If you move your residence from a network area (in area) to an out-of-area location during the year (or vice versa), any expenses you have incurred for out-of-network deductibles and coinsurance payments will move with you. However, the expenses you have incurred will also be applied toward any new plan limitations. In this way, the plan ensures you equitable consideration of your already-incurred expenses when your coverage status changes due to a move.

12. What is the definition of a multi-employer plan and a multiple employer plan?

A multi-employer plan is a group health plan that is organized under a collective bargaining agreement with collectively bargained health and welfare funds. A multiple employer plan is a health plan sponsored by two or more employers.

13. Who is eligible for Medicare?

There are three criteria to be eligible for Medicare: someone who is sixty-five years or older, someone who has end stage renal disease, or someone who is entitled to Medicare because of a disability.

14. How do you determine if Medicare is primary or secondary?

The individual or his/her spouse must be currently employed/working and covered under an employer group health plan as a result of current employment. In addition, the company must have 20 or more employees or be participants in a multiple/multi-group health plan where at least one employer has 20 or more employees. If the individual in question is entitled to Medicare as a result of a disability, the company must have 100 or more employees or be participants in a multi/multiple group health plan where one employer has 100 or more employees. If the individual in question is Medicare entitled due to end stage renal disease, Medicare is the secondary payer to a group health plan until a 30-month coordination period has ended.

15. What is Medicare Secondary Payer?

Medicare Secondary Payer (MSP) is the term used by Medicare when Medicare is not responsible for paying first. (The private insurance industry generally talks about "Coordination of Benefits" when assigning responsibility for first and second payment). The term "Medicare Secondary Payer" is sometimes confused with Medicare supplement. A Medicare supplement (Medigap) policy is a private health insurance policy designed specifically to fill in some of the "gaps" in Medicare’s coverage when Medicare is the primary payer. Medicare supplement policies typically pay for expenses that Medicare does not pay because of deductible or co-insurance amounts or other limits under the Medicare program.

16. What is the difference between active and initial pensioner coverage?

Total benefits are the same for active employees and initial pensioners. However, if the initial pensioner or any of his/her dependents are eligible to enroll in Medicare, those persons must enroll in order to have complete coverage. MILA will reimburse the initial pensioner for Medicare Part B premium costs actually incurred up to the regular Part B premium cost. MILA will not reimburse for late enrollment penalties or for any of Part A the pensioner may have. Dependents eligible for initial pensioner coverage are the same dependents that were eligible for active employee MILA coverage.

17. How Long will initial pensioner benefits be paid?

If the person qualified for MILA benefits on the day before s/he retired, s/he will be covered for initial pensioner benefits for as long as s/he would have been covered as an active member if s/he had not retired. The person will be covered for the Plan benefits for which s/he qualified as an active participant unless s/he also qualified for regular retirement benefit in a plan for which a greater number of hours is required. In this instance, initial pensioner benefits will end on the day prior to coverage as a regular pensioner. If the person is not yet entitled to regular pensioner benefits when initial pensioner benefits end, MILA benefits will cease and the person will be offered COBRA continuation rights.

18. What types of coverage are covered under the Core Plan?

Medical through CIGNA HealthCare. This coverage includes visits to the doctor's office, hospital, physical therapists, and other services like maternity, home health and hospice care, and emergencies.

Prescription Drugs through Caremark. The prescription drug program makes it easy to get prescriptions filled at local network pharmacies or by mail order

Mental Health and Substance Abuse through CIGNA Behavioral Health Care. Treatment for conditions like depression or drug and alcohol addiction is covered through the Mental Health and Substance Abuse Program.