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Health and Welfare Benefits

Using Your Health and Welfare Benefits
The Pennsylvania Faculty Health and Welfare Fund administers nine (9) different benefit programs, which are not a part of the basic Highmark Blue Shield (BS), and Major Medical (MM) health plans. The Fund is administered by ACA, Inc. The Fund was established through money negotiated in the collective bargaining process.

The following is a brief, step-by-step explanation of how to use your APSCUF Health and Welfare (H&W) benefits. This summary in no fashion replaces the most up-to-date version of the Program of Health and Welfare Benefits publication and announcements distributed by the Fund. PLEASE DO NOT PROVIDE THE FEE SCHEDULE INFORMATION LOCATED IN THE PROGRAM OF HEALTH AND WELFARE BENEFITS HANDBOOK TO YOUR MEDICAL PROVIDERS.

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Eligibility
Completing a BENEFIT ENROLLMENT CARD is the first step in qualifying for the Dental, Vision, Supplemental, Hearing Exam/Aid, Mammogram, Wellness, Health Maintenance Organization (HMO) Prescription Drug and Educational Leave Without Pay Programs. You may obtain your enrollment card from your campus APSCUF office or APSCUF Health and Welfare Specialist.

Eligible faculty members include all PERMANENT OR TEMPORARY FULL-TIME FACULTY. Part-time faculty members are now eligible for certain preventative benefits provided under the Fund.

Eligible dependents include spouse and any unmarried children (up until the day before their 19th birthday). If your child(ren) is/are single, full-time student(s) and dependent upon your support, they are eligible for Fund benefits up until the day before their 25th birthday. If a child has been medically deemed unable to support him or herself prior to the day before the 19th birthday, Fund benefits will continue contingent on documentation of the circumstances.

See "Program of Health & Welfare Benefits" for eligibility requirements for other dependents such as legal guardian. See "Program of Health & Welfare Benefits" for new policy on COVERAGE ENDING DATES. If both parents are Faculty Members, the dependent child(ren) may only be listed as such on ONE FACULTY MEMBER'S enrollment card (not both).

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Wellness Examination
The Fund will reimburse up to $125.00 of the cost for a routine physical examination once every 12 months for a faculty member and spouse who are age 45 or older.

The Fund will reimburse $125.00 of the cost once every 24 months for a faculty member and spouse who are 44 years of age or younger. Obtain the correct claim form from the local APSCUF office or APSCUF Health and Welfare Specialist and complete the required information. Go to a physician to obtain services, pay for the services and get an itemized bill with physician's signature, attach necessary receipts and forward to the Fund office.

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Mammography Examination
The Fund will reimburse up to $100.00 of the cost for a low dose, baseline mammogram examination once every 12 months for a faculty member or spouse who are **50 years of age or older. The Fund will reimburse $100.00 of the cost once every 24 months for a faculty member or spouse who are between the ages of 40 to 49 and once for a faculty member or spouse who are between ages 35 and 39. (Please see the Program of Health and Welfare Benefits Handbook for more detailed information.)

If your physician recommends a mammogram for medical reasons, the charges should be submitted to Highmark Blue Shield.
Highmark Blue Shield is required by state law to provide coverage for a routine mammogram for females over 40 years of age. Please see your SSHE Benefits Program Handbook for more details.

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Hearing Examination and Aid
The Fund will reimburse up to $120.00 once every 3 years for a hearing examination from a physician with a specialty in otolaryngology or an audiometric specialist. The Fund will reimburse one (1) hearing aid up to $700.00 and $350.00 for a second hearing aid or $1,050.00 if two (2) hearing aids are purchased at the same time. You may be eligible for this benefit once every 3 years IF a physician or audiometric specialist recommends an aid. To receive reimbursement, return completed claim form to the Fund office with the itemized bill(s). The bill(s) must include a description of the examination and/or the hearing appliance, the amount(s) charged for the examination and/or hearing aid appliance, the name of the person requiring the appliance and the doctor's certification.

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Dental Benefits
Schedule the appointment for you and/or your family with a dentist of your choice. Provide for your dentist a separate form for each family member receiving services. Have the regular and normal examination and services completed. Payment may be assigned to the dentist or yourself. Please sign the dental form appropriately. No matter what method of reimbursement is chosen, the patient/member and dentist signatures must appear on the claim form for processing.

If the dentist is contemplating dental work which exceeds $300.00, the services must be precertified by the Fund to ensure reimbursement. The normal claim form is used as the precertification form.

For eligibility rules and fee schedules see your Program of Health and Welfare Benefits Handbook.

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Orthodontia Services
The eligibility rules and fee schedules are located under Class IV Services (Dental Benefits) in your Program of Health and Welfare Benefits Handbook. It is important to have your orthodontist follow the schedule. The lifetime maximum per family member under the orthodontia services is $2,100.00. To obtain the remainder of the lifetime maximum, the faculty member must provide the Fund with documentation that shows the patient is in retention and the total bill has been paid.

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Vision Benefits
The eligibility rules and fee schedules are located in your Program of Health and Welfare Benefits Handbook.
Schedule an appointment for you and/or your family members with a professional eye care specialist of your choice. Provide the professional eye care specialist with a separate claim form for each family member receiving eye care services.
Pay for the eye care services directly. Vision reimbursements cannot be assigned to the provider. Complete the claim form and attach all necessary receipts and forward it to the Fund for reimbursement. The patient/member and the professional provider must sign the vision form. For traumatic eye care, please refer to your Program of Health and Welfare Benefits Handbook.

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Health Maintenance Organization (HMO) Drug Option
Since July 1, 1996, Faculty enrolled in HMO plans provided by the State System of Higher Education (State System) are provided with prescription drug coverage. The plan of benefits differs from HMO plan to HMO plan. In some instances, Faculty are required to pay co-pay amounts when obtaining prescription medications.

The Fund will deduct $50.00 of the $250.00 deductible, and then will reimburse 80% of the next $200.00. The Fund will reimburse the 20% co-pay amounts once $250.00 in co-pays are incurred per Faculty member and/or eligible dependents per calendar year. The Fund will reimburse for co-pays in excess of the first $250.00 up to a maximum of another $350.00.

In order to receive reimbursement from the Fund, those Faculty enrolled in HMO plans provided by the State System must submit original documentation to the Fund Office that shows at least $250.00 in co-pays have been paid. This evidence must be appended to a completed.

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HMO Drug Option claim form and mailed to the Fund Office.
The intent of this plan is to provide the Faculty enrolled in HMO plans with the same amount of reimbursement from the Fund provided to Faculty enrolled in the Blue Cross/Blue Shield Major Medical Plan. No reimbursement will be made for non-covered prescription medications, services or devices. It is recommended that Faculty submit claims for the reimbursement of HMO drug co-pays once each calendar year, if possible.

Faculty who have questions regarding this benefit are encouraged to speak with their campus Health and Welfare Specialist.

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Supplemental Plan
The Supplemental Plan has been created to coordinate reimbursement with the Major Medical Plan. The Supplemental Plan does not cover charges deemed ineligible under Major Medical. The Supplemental Plan does not coordinate benefits claimed under Highmark Blue Shield. Under Major Medical there is an annual $250.00 deductible which must be satisfied before the plan begins to pay at 80% of eligible charges. Once a faculty member and/or spouse/dependent satisfies the annual $250.00, the Fund will deduct $50.00 and reimburse 80% of the next $200.00 and the 20% co-pay portion of the Major Medical benefit.

The Fund requests that you hold your supplemental claim until at least $20.00 is reimbursable (this means at least $75.00 of the major medical deductible has been satisfied [$75.00 - $50.00 = $25.00 x 80% = $20.00]

To receive reimbursement, a covered subscriber/dependent must complete a Major Medical claim form, attach all receipts and forward to Highmark Blue Shield regional office. Major Medical will send an "STATEMENT OF CLAIMS (SOC)" which will state all charges submitted, eligible or ineligible, reimbursement due and a check if appropriate. The SOC will state if the subscriber/patient has satisfied the yearly deductible and show the 20% co-pay taken from the charges. Detach the MM check, complete a H&W Supplemental Claim Form, attach the SOC received and forward to the Fund. Once the $250.00 deductible is reimbursed, the Fund will continue to reimburse the 20% co-pay until the end of the year. Psychiatric claims are reimbursed under a different method. MM will reimburse at the level of 50% of $50.00 ($25.00) per visit and the Fund will pay an additional $25.00 per visit.

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Educational Leave Without Pay Benefits Plan
This plan is designed to assist those eligible faculty members who have elected, and have been approved by the university president, to go on an educational leave without pay. The faculty member must write a letter to the Fund stating the term of leave and eligible dependent(s) information. Accompanying this communication must be the letter received from the university president approving the educational leave. The Fund will provide H&W benefits and reimburse the COBRASERV and group life insurance premiums. SEPARATELY, the faculty member must apply and pay for benefits under COBRASERV for Highmark Blue Shield. Please refer to your Program of Health and Welfare Benefits Handbook for more details.

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Part-time Faculty Benefits
Part-time faculty who are employed at least 25% of full-time are eligible for the preventative care benefit package as long as they have satisfied the eligibility criteria of working one (1) semester in the preceding three (3) semesters at least 25% of full-time. The initial waiting period need only be satisfied once as long as the faculty member works at least one semester each academic year. Part-time faculty members who are employed for at least 25% to 49% of full-time are eligible for employee only benefits. Those faculty employed at least 50% to 99% of full-time have employee and lawful spouse benefits. Preventative benefits covered under this program are vision examinations, wellness examinations, mammography examinations, and dental examinations, cleanings and x-rays. Please refer to your Program of Health and Welfare Benefits Handbook for more details. This benefit became effective January 1, 1994.

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Continuation of Benefits Upon Termination
This program is mandatory under federal law. The government made available continuation of group benefits at 102% of the employer contribution under such circumstances as death, reaching age limitation for eligibility, divorces and termination have designed the program. Faculty members/dependents must pay the stated premium directly to the Fund to retain benefits. Please refer to your Program of Health and Welfare Benefits Handbook for more details.

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Coordination of Benefits
Any faculty member who has a spouse that is employed and covered another group health insurance plan MUST coordinate both insurance plans for reimbursement. Please refer to your Program of Health and Welfare Benefits Handbook for more details. See Program of Health & Welfare Benefits for new policy on subrogation.

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Vital Information
All claims forms for the PA Faculty Health and Welfare Fund can be obtained from the local APSCUF office or your local Health and Welfare Specialist. If you have questions and/or problems, please contact your local Health and Welfare Specialist. *Before sending any information/documentation to anyone, make copies of all materials forwarded. *Place your Program of Health and Welfare Benefits Handbook in a safe, accessible place. *When benefit announcements are received, place the information inside the booklet to keep it as up-to-date as possible.

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Local Health & Welfare Specialists - listed below. APSCUF's Health and Welfare Specialists:

Campus	H&W Specialist	Campus Phone
Bloomsburg California Cheyney Clarion East Stroudsburg Edinboro Indiana Kutztown Lock Haven Mansfield Millersville Shippensburg Slippery Rock West Chester	Bruce Rockwood Bruce Barnhart Michael Thomas Elizabeth Donato Robert Fleischman Karl Nordberg Mike Sell Stephanie Steely Jeffrey Burnham Bernard Sabol Judith Halden-Sullivan Michael Marshall Armand Policicchio Sheri Melton	570-389-4760 724-938-4562 610-399-2350 814-393-2296 570-422-3316 814-732-2721 724-357-2261 610-683-4745 570-893-2554 570-662-4638 717-871-2134 717-532-1667 724-738-2689 610-436-2146

These people serve APSCUF members voluntarily. Be sure to thank them for their time and effort on your behalf.

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