Board of Trustees - 2006-2007:
| Name |
Term Expires During |
| Linda Armston |
2008 |
Bob Cunningham
|
2008 |
| Gail Diamond |
2008 |
| Glenn Gallagher |
2009 |
| Bill Tubby |
2009 |
| Laura Sexton - Treasurer |
2009 |
| Lauri J. Naccarato - Chairperson |
N/A |
| Hugh Spoljaric - Executive Director |
N/A |
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Schedule of Trust Meetings
All of the meetings below are scheduled for 3:30 pm in Room 106 at
Kingston High School:
January 1, 2008 Dental Schedule
See PDF
January 2007 Trust Modifications
Click here for the modifications. They will open in a new window.
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June 2006 Trust Modifications
Notice of Material
Modifications and Amendments
The Trustees of
the Kingston Trust Fund have a fiduciary responsibility to respond proactively,
as the medical industry changes, to any impacts on the plan that need to be
addressed. Many other plans fail to address changes and continue to raise
premiums. Compared to all other plans in the United States, the Trust plan
provides a superior benefit package and at no cost to the members. Additional
benefits, like stroke screening, are provided at nominal cost.
Some concerns are
beyond local control. Presently, for example, medical ID’s and prescription
ID’s, in the industry, do not follow the same criteria and use two separate ID’s
(an encrypted medical and a Social Security prescription). The medical card is
encrypted to prevent identity theft. Adding another card with your Social
Security number (for prescriptions) could prove costly to the member and to the
Trust. In the future, to enhance security, a picture ID card would further
enhance security.
Therefore, the
following changes have been adopted and agreed to by the Trustees and shall be
made effective as July 1, 2006. Please keep a copy of this Amendment and
Notice of Material Modification with your plan booklet.
1. The Rx
Out of Pocket (OOP) limit has been increased to $1,500 from $1,000. This is
the first increase in the Rx OOP limit since the plan’s inception. This limit
is significantly less than the OOP limit under Medicare. The Rx coverage under
the NHAI plan continues to Creditable Coverage for purposes of the Medicare part
D Program.
2. The Rx
copays have been increased to $10 for generic and $20 for brand for a 30-day
refill at your local pharmacy. For mail order, the generic copay
is $15 and the brand copay is $30 for a 90-day refill. Further, if diabetic
supplies and drugs are filled at the retail level, the normal retail copay will
apply.
3. The
Emergency Room copay is now $75 for acute emergency treatment. The ER copay
for non-acute treatment is now $125 and the balance of the expenses shall be
paid at 80% subject to the out of pocket limit. The ER Copay is waived if an
individual is admitted within 24 hours.
An emergency or life threatening condition
is defined as any accident or illness that requires immediate treatment to
relieve the sudden onset of severe pain, fever, swelling, serious bleeding,
severe discomfort and to the extent that treatment cannot be delayed until the
following day during normal business hours where treatment can be rendered by
your own physician or at an Urgent Care Center.
4. The
Physician Office Visit Copay (POV) is increased to $15 from $10 and
the Specialist Office Visit Copay (SPOV) is increased to $25 from $20 as
of July 1, 2006. The Chiropractic Copay remains at $20.
5. Durable
Medical Equipment (DME) shall now be paid at 90% with 10% coinsurance in
Network or 80% Out of Network with 20% coinsurance up to the Out of Pocket (OOP)
limit. Repairs to DME will be paid at 80% with no deductible.
6. The
monthly COBRA premium as of July 1, 2006 shall be $404 for single medical
Coverage and $1,001 for family medical coverage. The Dental COBRA premium is
$23.57 for single and $73 for family. COBRA Premium will be updated each July
l. This is the first increase in COBRA premiums since 3/1/2004. The COBRA
costs are significantly less than the actual district funding cost.
7. The
copays for BASIC lab and x-ray will remain at $15. However, the copays for
complex imaging shall be as follows. Most plans today will not cover the
following tests at all. Most of the tests that fall under item c below are
considered “experimental†by major insurers and are not covered at all. Some of
the new tests that are now available may only be offered by one entity, which
keeps the costs of such tests quite high. NHAI plans continue to take a leading
stance on preventive and progressive treatment and these modest copays make such
treatment available for coverage under the Kingston Trust Fund Plan.
a. The copay
for Complex Imaging and Diagnostic Testing (MRI’s, Cat Scans, Complex CT
Scans, Cardio Electro grams and Complex Diagnostic Tests costing $750 or more)
shall be $100.
b. The copay
for Ultra Fast Heart Scan, Heart/Chest Scan, or Liver Scan is now $50.
c. The copay
for Chest CT Angiography, Genomic Health Oncotype Diagnostic for Breast Cancer
or other State-of-the Art Complex Imaging or Lab Tests with a cost in excess of
$2,500 is now $200.
8. The
Precertification requirement for MRI’s and Cat Scans is being reinstated and
will now be required along with other diagnostic lab or x-ray test that costs
$1,000 or more.
9. Case
Management is monitored on behalf of the Plan by NHAI. One important element of
the Case Management benefits that are unique to NHAI is that NHAI plans have
always provided for certain “extended treatment†beyond the basic
benefits provided by the plan. Extended benefits are not available under
generally provided by traditional health care plans. NHAI plans have always
provided for extended benefits for therapy, home health care, skilled nursing,
etc. under case management when additional benefits were medically necessary.
While extended benefits continue to be available under NHAI’s case management
program, there have been some changes. First, the normal copays and/or
coinsurance as specified in the plan now apply to extended treatment and the
copays or coinsurance on the extended treatment will not be credited toward your
out of pocket (OOP) limit nor subject to the plan OOP limit. Example:
If physical therapy treatment is required beyond the normal 50 visits,
additional treatment approved under case management would be available, subject
to the same copay.
Extended benefits for home health care
or skilled nursing benefits will be paid at 50% and limited to 50
additional visits or days. Long term care, custodial care, and nursing home
care are not covered benefits under any group health plan. It is recommended
that members consider purchasing Long Term Care to cover this potential need.
Listed on the Trust web site is a detailed
explanation of Coordination of Benefits for the plan. Go to the KTF site at
www.NYSUT.org and click on Kingston Trust Fund.
Updated ID Cards will be issued soon.
Also, there will be a new Hotline available for providers and members to call
for a pre-recorded message that will provide the current copays, deductible and
out of pocket limits for your plan. This will eliminate the necessity to mail
out new ID cards whenever there is a change in the basic benefits. Should you
have a specific question about your benefits, contact the Compliance Office at
1-888-679-2400, Ext. 5.
DENTAL
Modifications and Amendments
As
of July 1, 2006, spouses or domestic partners who are eligible for dental
coverage through the Kingston Trust Fund and who are both active and/or retired
employees of the Kingston Schools, may designate only one family dental plan for
coverage under the Fund.
The annual dental claim expenditure shall
be capped at $2000 per person.
Schedule of Benefits: Class 1, #8, add: “except in the case of
periodontal prophylaxis where members are eligible for two additional
maintenances.â€
Foreign Travel Reminder
IMPORTANT REMINDER FOR FOREIGN TRAVEL
With the
summer travel season upon us, members are reminded that if they intend to travel
outside the U.S., Mexico or Canada, travel insurance is highly recommended.
Benefits outside the U.S., Mexico and Canada are limited to emergency treatment,
which will be paid at 80% after a $250 copay. Any non-emergency treatment would
be subject to prior approval and pre-certification as well as the NPPO
deductible as a copay for each incident, as all such treatment is out of
network.
If members or their
dependents plan to travel to war zones, you should also be aware that benefits
may be denied due to injuries incurred as a result of an act of war, such as a
suicide bomber in such countries as Israel, Iraq or other high risk countries.
|
Foreign Travel
(Outside the U.S., Mexico or Canada) |
N/A
Paid
at 80% after $250 copay (waived if admitted within 24 hours) |
Only
emergency treatment is covered while traveling, up to a maximum of six
(6) weeks outside the U.S. in any one country. Vacation travel
insurance is recommended for extended coverage. No benefit will be
provided after six (6) weeks in any one country or three (3) months of
consecutive travel. Foreign treatment is also subject to NPPO
deductible. |
Treatment
Outside the U.S., Canada, or Mexico:
Treatment is not covered, except for emergency treatment, while traveling
“temporarily†for a period not exceeding six (6) weeks in anyone country or
three (3) months in total. Any service provided outside the U.S., Canada, or
Mexico will be subject to the normal NPPO Plan deductible as copay for each
incident. The deductible/copay
will not
be credited to your NPPO deductible or out-of-pocket limit under the Plan.
After the deductible/copay is met, the member will be responsible for the basic
NPPO coinsurance up to the NPPO Out-of-Pocket limit for emergency service or for
any other non-emergency service as pre-approved by the Plan.
Non-emergency treatment of
chronic illness requiring hospitalization outside the United States will not be
covered unless the treatment is pre-authorized within 24 hours of admission (72
hours if hospitalized over the weekend). No approved services for medical
services rendered outside the U.S. are covered.
Emergency Treatment in Canada or
Mexico will be subject to the same Emergency Room copay as treatment within the
U.S.
Retirees living
permanently outside the U.S. are covered, according to the NPPO Schedule of
Benefits, as long as proof of residency is provided and non-residence status is
approved by the Plan, in advance. The approval will be at the sole discretion
of the Plan, based on all relevant facts and circumstances, including the
country in which the retiree resides. Coverage in countries considered “high
risk†areas will not be approved, subject to the sole discretion of the Plan.
Students on exchange-type programs are not covered. Parents are advised to
secure special travel and medical insurance through their travel or insurance
agent, through their school for extended travel, or if they or a dependent
intends to live abroad for an extended period.
War/Service in Armed Forces:
Expenses that result from loss or damage directly or indirectly, due to any act
of war (whether war is declared or not), including resistance to armed
aggression, will not be covered unless otherwise required by law.
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JANUARY 2006 TRUST
MODIFICATIONS
Amendment and
Notice of Material Modification
To the
KINGSTON TRUST
Domestic Partner
coverage shall now be available in accordance with the collective bargaining
agreement(s) covering members electing coverage under the Kingston Trust. The
following changes have been adopted and agreed to be the Trustees following a
special meeting and shall be made effective January 1, 2006 unless otherwise
indicated. Please keep a copy of this Amendment and Notice of Material
Modification with your plan booklet.
1.
Basic Domestic Partner Rules as Adopted
by the KTF Plan Trustees:
a. Domestic
Partner coverage shall be provided only to those members covered by a
collective bargaining agreement that provides for coverage of Domestic Partners
by the District.
b. Domestic
Partner coverage shall apply to unmarried same sex or opposite sex
partners who are 18 or older and have maintained a Domestic Partner relationship
and financial interdependence for at least one full year, subject to
documentation satisfactory to the Plan.
c. COBRA
shall apply for Domestic Partners the same as it would for a legally wed
spouse.
d. Children of
Domestic Partners may be covered if the children are a legal dependent
of the Domestic Partner or the member and reside with the member and their
Domestic Partner. The cost of any coverage for
children who are not a legal dependent of the member (the individual with
Primary Coverage) must be imputed to the
member and will be considered taxable income. Members are advised to contact
their CPA or tax attorney for advice with respect to the new rules governing
dependents under
§152(d) of the Code. See item
f below.
e. An
unmarried Domestic Partner is eligible to be covered by a member, even though
the Domestic Partner is not a legal dependent of the member.
f. The
cost of coverage paid for by the District for any Domestic Partner
or any dependent of the Domestic Partner who
is not a legal dependent of the member will be included as a taxable fringe
benefit by the District on the member’s W-2 each year. A Dependent Tax
Affidavit must be filed with the Trust each December attesting to whether or
not your Domestic Partner is or is not a legal dependent of the KTF member.
An affidavit is also required for any covered dependent
of your Domestic Partner to determine whether or not they are eligible
dependents of the member.
g. The cost of
Domestic Partner MEDICAL coverage for both active and retired members will be
paid by the District in accordance with the collective bargaining agreement
applicable to the member.
h. The
cost of DENTAL coverage for any Domestic Partner of a retiree must be paid by
the retired member. For retirees, the cost of dental coverage will be 2 x
the single premium if there are no dependent children. The family rate will
apply if any dependent children are covered. Dental premiums must be paid in
advance at the beginning of each quarter.
i. The rules
to cover a Domestic Partner for the Dental Plan will be the same as the rules
for Medical coverage of a Domestic Partner, except for the cost of dental for
retirees.
j. Domestic
Partner coverage for retirees shall be the same as for active employees.
Domestic partner coverage for retirees shall be the
same as for active employees. A retired member may add a Spouse, Domestic
Partner, or Dependant Child after their retirement due to a change in family
status.
k.
Extended COBRA coverage shall
be extended to the widowed spouse or Domestic Partner of Retiree.
A widow or widower, including a Domestic Partner, of a retiree shall be
permitted to continue coverage for their lifetime (subject to COBRA rules) after
the initial COBRA period (36 months) expires. During the initial COBRA period,
the widowed spouse may add a new spouse or dependents but they may only be
covered during the initial COBRA period and are not eligible for extended
Coverage beyond the initial COBRA period. Shall continue to be subject to the
basic COBRA rules with respect to payment and lapse of coverage. Extended COBRA
coverage for any dependents not covered at the time of the initial COBRA event
(death or divorce) is not available after the COBRA period expires (36 months.)
The member must request continued coverage under this option and payments to
retain coverage will continue to be subject to the COBRA rules.
2.
Coverage for
Domestic Partners:
In order for Domestic Partner coverage through NHAI the following criteria must
be met:
a. Both
partners must be eighteen years of age or older and unmarried. If either or
both partners have ever been married, evidence of the termination of the
marriage must be provided.
b. The
Domestic Partners must not be related by blood in a manner that would bar
marriage under the laws of the State of New York or state of residence.
c. Each
Partner must be the other’s sole Domestic Partner for at least twelve months
prior to the date of this affidavit, and intend to remain so indefinitely. The
Partners must affirm that they are in a relationship of mutual support, caring
and commitment, and have assumed responsibility for each other’s welfare.
d.
The Domestic Partners must have been living together at the same address,
on a continuous basis for at least twelve months prior to the date of this
affidavit.
e. One member
must be enrolled and/or eligible to enroll in the KTF/NHAI Plan.
f.
Neither member may have been enrolled or registered as a member of
another Domestic Partnership within twelve months.
g.
The enrollee must affirm that they will file a Termination of Domestic
Partnership form within 14 days of the date I/My partner no longer meet one or
more of the qualifying criteria set forth above.
h.
The enrollee must submit forms for “proof of twelve month residencyâ€
“Affidavit of Financial Interdependence†and “Dependent Tax Affidavit†in
addition to an enrollment or Change in Status form, once the Domestic Partner
eligibility has been approved by the Trust.
i.
The member must
also provide a copy of their “registry†as a Domestic Partner in your
municipality if required. The following states currently have cities with
such registries: California, Colorado, Connecticut, Florida, Georgia, Hawaii,
Illinois, Iowa, Maine, Maryland, Minnesota, Missouri, North Carolina, New York,
Oregon, Texas, Washington, and Wisconsin.
j.
Any covered
dependent must meet the “relationship test†under
§152(d)
of the Code in order to be eligible for coverage. Otherwise, the cost of such
coverage is considered taxable in accordance with the rules in Section 1,
paragraphs de and f.
3.
Proof of Financial
Interdependence:
Domestic Partners who reside together and are financially interdependent must
submit original documents of the following items
(at least one of
the two items must be from list A)
as proof of our financial interdependence:
List A
A.
Joint obligation on a loan
(including an affidavit by a creditor for a personal loan
B.
Joint ownership of our residence
C.
Joint renters or home owners
insurance policy
D.
Joint responsibility for child
care (school documents, guardianship)
E.
Designated as beneficiary under
the other’s life insurance policy, retirement benefits account or will or
executor of each other’s wills.
F.
An affidavit by a creditor or
other person able to testify to partner’s financial interdependence.
G.
Mutually granted durable power of
attorney
H.
Designated of one partner as the
payee for the others government benefits
I.
Joint ownership or holding of
investments
J.
Joint ownership or lease of a
motor vehicle
K.
Both listed as tenants on the
lease of our shared residence
L.
Mutually granted authority to make
health care decisions (healthcare power of attorney)
M.
Share a household budget for the receiving government benefits
List B (must provide proof of at
least one of the following:
a.
Joint bank account
b.
Joint credit card or charge
c.
Status as authorized signatory on the partner’s bank account, credit card
or charge card
d.
Other proof establishing economic interdependence
-
Proof of Twelve –
Month Residency: To enroll your
Domestic Partner in the KTF/NHAI benefit program you must submit a copy of
one item of proof that you and your partner have resided together for at
least twelve months. The proof may be one document with both names or two
separate documents that show the residence of each partner. The following
is a list of some items that can be used to demonstrate proof of residency.
You may submit a copy of another document that proves residency began at
least twelve months ago.
a.
Driver’s License
b.
Auto registration
c.
Lease agreement
d.
Mortgage agreement
e.
Tax return
f.
Bank statement
g.
Passport
h.
Insurance benefits statement
i.
Paycheck stub
j.
Utility bill
k.
Telephone bill
l.
Joint membership (church, or family association)
The above changes
were adopted and approved by the Board of Trustees for the Kingston Trust Fund
at the Special Trustee Meeting on November 29, 2005.
Approved:
________________________ Date: _____________________
Hugh Spoljaric, Chairman
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|
|
Dental Services Covered |
|
Dental Benefits |
Dental
Benefits will be paid in accordance with the following schedule with No
deductible, nor any annual limit on benefits:
Class 1—Preventive
Benefits:
60%
Class 2—Basic Restorative
Benefits: 60%
Class 3—Major Restorative
Benefits 60%
Class 4—Orthodontics (to age 19)
0% |
|
Class 1
Preventive and
Basic Services |
Cleaning, prophylaxis and routine oral
exam (once every 6 months), bite wings (one x-ray series every 12
months), diagnostic tests, sealants, palliative treatment, space
maintainers, and fluoride treatments as follows: Oral
examinations include examinations when the Dentist first examines you to
determine if further dental care is required.
1.
We will not pay for more than two routine oral examinations
during any twelve-month period, or emergency palliative treatments
for the purpose of removing or alleviating pain and sedative fillings.
2. If
additional dental services are provided (other than x-rays) on the same
day, we will not make a separate payment for the oral examination.
3. We
will not pay for bitewing x-rays more than twice during any twelve
month period.
4.
Occlusal and extra-oral x-rays will not be paid for more than a total
of 2 films in any 24-month period.
5.
Panoramic or full mouth x-rays will not pay be paid for more than one
panoramic of full mouth x-ray in any 36-month period.
6. We
will only pay for fluoride applications for children age 18 and younger.
7. We
will not pay for more than two fluoride applications in any 12- month
period. Prophylaxis includes polishing and scaling.
8. We
will not pay for more than two prophylaxes during any twelve-month
period.
9.
For persons over age 18, the prophylaxis may include periodontics
prophylaxis.
10.
Sealants shall be covered to age 18 or as medically necessary. |
|
Class 2
Dental and
X-Rays
|
Diagnostic tests, emergency treatment,
recementation, anesthesia, restorations, fillings, amalgams, composites,
pulp caps, oral surgery, periodontal.
1.
The fillings may
consist of silver amalgam and or tooth color restorations using
synthetic materials.
2.
Our payment for the filling includes payment for local
anesthesia or direct pulp capping on the same date as the filling.
3.
We will pay for the extraction of teeth including
extractions by surgery. The oral surgery may consist of treatment of
fractures and dislocations and diagnosis and treatment of cysts,
abscesses and impaction. |
KTF DENTAL PLAN SCHEDULE
OF BENEFITS
|
Class 3
Major Services
|
Class 3 services will be covered for
repairs to bridges, crowns, endodontics, repairs to dentures,
periodontics, scaling, root planning, anesthesia and partials.
Covered services include—
1.
Repairs to full or partial dentures or to bridges,
including surgical periodontics examination; gingival curettage;
gingivectomy and gingivoplasty; osseous surgery including flap entry and
enclosure; mucogingivoplastic surgery; and management of acute
infections and oral lesions.
2.
Periodontics treatment of the same portion of the mouth is
limited to once every 12-month period.
3.
Periodontal surgery if you were covered under this Plan on
the date the surgery is actually performed.
4.
Space maintainers for children up to age 14 and any
adjustments, which are made within six months of the installation of the
space maintainers. The apicectomy may include flap surgery, apical
curettage, local anesthesia, x-rays and post-operative care.
5.
Inlay services are covered when the teeth cannot be
restored by filling, local anesthesia, direct pulp capping on the same
date as cementation, indirect pulp capping, lab charges, base, pins, gum
preparation and temporary restoration. Replacement of inlays is limited
to once every five years.
6.
Crowns are covered when the teeth cannot be restored by
other means and when the crown is not part of a bridge. Crowns for the
purpose of periodontal splinting is not covered, but services for local
anesthesia, direct pulp capping done on the same date as cementation,
indirect pulp capping, lab charges, base, pins, gum preparation and
temporary restoration is not covered. Crowns can be replaced once every
five years if medically necessary.
7.
For child crowns (up to age 14), covered services include
pulpotomy, including local anesthesia, x-rays, pulp capping, temporary
fillings and post-operative care.
8.
Root canal therapy, including anesthesia, x-rays,
pulpotomy, temporary fillings and post-operative care is covered. |
|
Extended
Benefits (must be
completed within 30 days of termination)
|
Benefits will be extended
for a dental procedure that began before the date a person’s coverage
terminated and which was completed within 30 days after the termination
date, if the covered charge is for any of the following:
1. A
removable appliance or modification of an appliance for which an
impression is made.
2. A
fixed bridge, crown, gold or cast restoration when the tooth or teeth
are fully prepared.
3.
Root canal therapy when the pulp chamber is opened and explored to the
apex, provided you or your dependents do not become covered under any
other Group Dental Plan for that dental procedure. |
EXCLUSIONS
|
Dental
Exclusions |
Charges for the following shall not
be covered unless specifically listed as a covered service in the
above schedule of benefits:
1.
Orthodontia benefits are not provided or covered by this Plan.
2.
Replacement of a lost or stolen appliance.
3.
Implants or any prosthetic device attached to them or precision or
semi-precision attachments, unless medically necessary.
4.
Instruction in oral hygiene or plaque control, completion of any forms
or failure to keep any scheduled appointment.
5.
Dental procedures performed solely for cosmetic reasons or to
characterize or personalize dentures or bridges.
Examples of Cosmetic Procedures:
Porcelain overlays and teeth whitening are both considered a cosmetic
procedures according to the IRS.
6.
Replacement of a bridge or denture that meets or can be made to meet
generally accepted dental standards.
7.
Appliance or restorations except full dentures, to change vertical
dimension, or restore occlusion or correct Temporomandibular Joint
Dysfunction (TMJ). Diagnostic procedures for each are also excluded.
8.
Dental procedures performed while you or your dependents are not insured
for these benefits. This includes procedures begun before a person’s
effective date of dental care insurance although partially performed
after that date.
9.
Dental injuries incurred as a result of “biting†or “chewing†will only
be covered under the Dental Plan and not considered as an accident
benefit under the Group Health Plan.
10.
Charges for filing a claim.
11.
Dental procedures performed because of an occupational injury or
sickness.
12. Gold
foil restoration.
13. Oral
hygiene instruction; bacteriological studies; caries susceptibility
tests; pulp vitality tests; diagnostic photographs; or diet planning.
14.
Consulting with another Dentist on the same day your Dentist provides
service covered under this Plan.
15.
Athletic mouth guards; sealants; analgesia; implants; Occlusal analysis;
replacement of lost or stolen appliances; myofunctional therapy;
precision or semi-precision attachments; denture duplication; charges
for broken appointments.
16.
General anesthesia, except that benefits are paid for general anesthesia
in connection with complex oral surgery, covered under this Plan.
17.
Other procedures not included on the above list of covered services or
services which do not have uniform professional endorsement.
18.
Prescription and non-prescription drugs. Any prescription drugs
prescribed by a dental provider are covered the same as any other Rx
under the General Health Plan.
19.
Dental services neither considered within the scope of normal,
acceptable dental practice nor consistent with the highest ethical
dental standards of the dental profession.
20. No
benefits will be provided for Orthodontic services or Orthognathic
surgery.
21.
Major restoration services, Prosthodontics, removable or fixed.
22. Any
cosmetic procedure such as tooth whitening. |
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JULY 2005 TRUST
MODIFICATIONS
Effective July 1, 2005, as adopted by the Trustees of
the Kingston Trust on May 24, 2005, regarding chiropractic services:
In a situation where there is a penalty both for failure to
pre-certify benefits and for untimely filing of claims, the maximum
penalty will be limited to 50%, subject to a maximum benefit of
$25,000 if the claim is not filed prior to the end of any plan year
(9/30) or within 90 days of the date of service, if later.
The amendment is actually a benefit for members. The late
filing of claims (beyond 90 days) would result in a complete loss of
the benefit as per the plan document. Some chiropractic claims
involve letters of referral and medical necessity and, as such,
delay the timely filing. This amendment limits the penalty.
LEGAL CHANGES:
In
2002, a statute was enacted that required that the practice of
psychotherapy and counseling be limited to persons who are licensed
in the professions of psychology, medicine (including physicians and
physician assistants), nursing, licensed master social workers,
licensed clinical social workers, and the four new mental health
professions of:
Licensed mental health counselor,
Licensed psychoanalyst,
Licensed marriage and family
therapist, and
Licensed creative arts
therapist.
The law has been
made effective over a series of dates:
For
psychology, medicine, and nursing, the effective date was September
1, 2003;
For the social
work professions, the effective date was September 1, 2004; and,
For the four
new professions, the effective date was January 1, 2005. **
** For the four new professions,
January 1, 2006 will be the date on which persons can be prosecuted
for the illegal practice of the four new professions. During 2005,
they will have the opportunity to apply for licensure or a limited
permit.
Individuals who
have practiced psychotherapy or counseling have been able to do so
without licensure, as long as they have not used the restricted
titles or terms or engaged in the scope of practice of medicine,
nursing, and psychology until September 1, 2003 or engaged in the
practice of the two social work professions until September 1,
2004. Since January 1, 2005 unlicensed individuals have been able
to continue the practice of counseling and psychotherapy while
applying for licensure in the four new professions, and will not be
prosecuted for doing this until January 1, 2006.
NHAI will be requiring all the new professions to
provide proof of licensing prior to be approved to be a provider
under any of the NHAI plan, along with proof of Errors and Omissions
Insurance (E&O). Any
provider who is not duly licensed in the state in which they provide
services will not be covered under this plan. These
new rules have an impact on many behavioral providers who have
previously not been required to be licensed. The new professions
must provide documentation that licensure has been applied for after
July 1, 2005 in order for any future services to be covered.
Special Note to Medicare
Retirees:
Effective January 1, 2005, benefits for services provided by any of
the new behavioral specialties that must now be licensed who
refuses to accept Medicare assignment or to bill Medicare, will be
limited to 35% of allowed charges for any member
where Medicare is the primary
plan. Such provider will be
considered a “contract provider†for Medicare and will not be
covered by Medicare.
We recommend that anyone going to any counselor verify with
their counselor that they are currently licensed to practice their
particular specialty and whether or not they accept Medicare. You
may want to consider changing providers if your provider is not
appropriately licensed or if they will not accept Medicare. The
Behavioral Health Office will be glad to assist you in locating a
new provider. (1-888-679-2400, select 3).
If any additional information or questions are
required concerning this communication, please feel free to contact
the Compliance Office. (select 5)
