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<s>[INST] What is the overall deductible? [/INST] IN-NETWORK: $0/Individual & $0/Family. OUT-OF-NETWORK: No Out-of-Network coverage other than emergency services. In-Network benefits apply. This plan will begin paying immediately and there is no deductible. Only copayments and coinsurance will be required until the out-of-pocket limit is met. </s> |
<s>[INST] Are there services covered before you meet your deductible? [/INST] IN-NETWORK: YES & OUT-OF-NETWORK: YES. This plan covers certain preventive services without cost-sharing. Covered preventive services are listed at https://www.healthcare.gov/coverage/preventive-care-benefits/. In-networkpreventive care and prescriptions are not subject copayments. No Out-of-network preventive care / prescriptions are covered. </s> |
<s>[INST] Are there other deductibles for specific services? [/INST] IN-NETWORK: NO & OUT-OF-NETWORK: NO. There are no other deductibles for specific services. </s> |
<s>[INST] What is the out-of-pocket limit for this plan? [/INST] IN-NETWORK: $3,500/Individual & $7,000/Family. OUT-OF-NETWORK: No Out-of-Network coverage other than Emergent/Urgent & In-Network benefits apply. The out-of-pocket limit is the most you could pay in a year for covered services. Copayment, and coinsurance amounts DO count toward your out-of-pocket limit. In families of 2 or more members, if family out-of-pocket limit is met cumulatively, expenses are payable at 100% for all family members even if the individual out-of-pocket limits haven’t been met by each member. </s> |
<s>[INST] What is not included in the out-of-pocket limit? [/INST] Balance-billing charges, and excluded expenses this plan does not cover. Even though you pay for these expenses, they DO NOT count toward your out-of-pocket limit. This includes out of network services that are not an emergency. </s> |
<s>[INST] Will you pay less if you use a network provider? [/INST] YES. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, as these services are not covered unless a true emergency so you will pay the full cost. You can access in-network provider listings by visiting dfwconnectedcare.com, or call 1-888-860-6178. </s> |
<s>[INST] Do you need a referral to see a specialist? [/INST] NO. You can see the specialist you choose without a referral as long as they are in-network. </s> |
<s>[INST] Which services may I need if I visit a health care provider’s office or clinic? [/INST] 1. Primary care visit (including telemedicine) 2. Specialist visit (including telemedicine) 3. Doctor on Demand Telehealth visit 4. Preventive care/screening/ immunization </s> |
<s>[INST] What will I pay for Primary care visit (including telemedicine) at a health care provider’s office or clinic? [/INST] If you are a Network Provider (You will pay the least): $15 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. No Limitations, Exceptions, & Other Important Information. </s> |
<s>[INST] What will I pay for Specialist visit (including telemedicine) at a health care provider’s office or clinic? [/INST] If you are a Network Provider (You will pay the least): $50 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. No Limitations, Exceptions, & Other Important Information. </s> |
<s>[INST] What will I pay for Doctor on Demand Telehealth visit at a health care provider’s office or clinic? [/INST] If you are a Network Provider (You will pay the least): $10 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. No Limitations, Exceptions, & Other Important Information. </s> |
<s>[INST] What will I pay for Preventive care/screening/ immunization at a health care provider’s office or clinic? [/INST] If you are a Network Provider (You will pay the least): No cost to you. If you are Out-of-Network Provider (You will pay the most): Not covered. Charges will apply for services and tests which fall outside USPSTF guidelines </s> |
<s>[INST] Which services may I need If I have a test at a hospital facility? [/INST] 1. Diagnostic test (x-ray, labs) 2. Imaging (CT, PET, MRI) scans </s> |
<s>[INST] What will I pay for Diagnostic test (x-ray, labs) at a hospital facility? [/INST] If you are a Network Provider (You will pay the least): $50 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. No Limitations, Exceptions, & Other Important Information. </s> |
<s>[INST] What will I pay for Imaging (CT, PET, MRI) scans at a hospital facility? [/INST] If you are a Network Provider (You will pay the least): $400 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. No Limitations, Exceptions, & Other Important Information. </s> |
<s>[INST] Which services may I need If I have a test at the doctor’s office? [/INST] 1. Diagnostic test (x-ray, labs) 2. Imaging (CT, PET, MRI) scans </s> |
<s>[INST] What will I pay for Diagnostic test (x-ray, labs) at the doctor’s office? [/INST] If you are a Network Provider (You will pay the least): No cost to you. If you are Out-of-Network Provider (You will pay the most): Not covered. Charges apply if performed in a hospital. </s> |
<s>[INST] What will I pay for Imaging (CT, PET, MRI) scans at the doctor’s office? [/INST] If you are a Network Provider (You will pay the least): $100 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. Charges apply if performed in a hospital </s> |
<s>[INST] What are the types of drugs that can be prescribed to treat my illness or condition?What are the types of drugs that can be prescribed to treat my illness or condition? [/INST] 1. Generic drugs 2. Preferred brand drugs 3. Non-preferred brand drugs 4. Specialty drugs. More information about prescription drug coverage is available at www.caremark.com </s> |
<s>[INST] What will I pay for the Generic drugs prescription retail? [/INST] If you are a Network Provider (You will pay the least): Up to a 30-day supply $20 copayment. Up to a 90-day supply $40 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. You will pay the cost of the prescription drug if it is less than the copayment.Certain brand name prescription drugs are not covered, check with CVS Caremark at www.caremark.com Prescription drugs do not have a deductible . If you fill the same prescription drugs in a 30-day supply quantity or less 3 times, you will pay 175% of the copayment on the 4th and consecutive fills. If you select a preferred or non-preferred brand drug when a generic is available, you pay the copayment plus the cost difference between generic and preferred or non-preferred brand. Some prescription drugs require preauthorization. Up to a 30-day supply can be filled through a CVS Caremark network pharmacy for in-network benefits. Up to 90-day prescription fills are only available. </s> |
<s>[INST] What will I pay for the Generic drugs prescription mail order? [/INST] If you are a Network Provider (You will pay the least): Up to a 90-day supply $40 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. You will pay the cost of the prescription drug if it is less than the copayment.Certain brand name prescription drugs are not covered, check with CVS Caremark at www.caremark.com Prescription drugs do not have a deductible. If you fill the same prescription drugs in a 30-day supply quantity or less 3 times, you will pay 175% of the copayment on the 4th and consecutive fills. If you select a preferred or non-preferred brand drug when a generic is available, you pay the copayment plus the cost difference between generic and preferred or non-preferred brand. Some prescription drugs require preauthorization. Up to a 30-day supply can be filled through a CVS Caremark network pharmacy for in-network benefits. Up to 90-day prescription fills are only available </s> |
<s>[INST] What will I pay for the Preferred brand drugs prescription retail? [/INST] If you are a Network Provider (You will pay the least): Up to a 30-day supply $50 copayment. Up to a 90-day supply $100 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. You will pay the cost of the prescription drug if it is less than the copayment. Certain brand name prescription drugs are not covered, check with CVS Caremark at www.caremark.com Prescription drugs do not have a deductible. If you fill the same prescription drugs in a 30-day supply quantity or less 3 times, you will pay 175% of the copayment on the 4th and consecutive fills. If you select a preferred or non-preferred brand drug when a generic is available, you pay the copayment plus the cost difference between generic and preferred or non-preferred brand. Some prescription drugs require preauthorization. Up to a 30-day supply can be filled through a CVS Caremark network pharmacy for in-network benefits. Up to 90-day prescription fills are only available. </s> |
<s>[INST] What will I pay for the Preferred brand drugs prescription mail order? [/INST] If you are a Network Provider (You will pay the least): Up to a 90-day supply $100 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. You will pay the cost of the prescription drug if it is less than the copayment.Certain brand name prescription drugs are not covered, check with CVS Caremark at www.caremark.com Prescription drugs do not have a deductible. If you fill the same prescription drugs in a 30-day supply quantity or less 3 times, you will pay 175% of the copayment on the 4th and consecutive fills. If you select a preferred or non-preferred brand drug when a generic is available, you pay the copayment plus the cost difference between generic and preferred or non-preferred brand. Some prescription drugs require preauthorization. Up to a 30-day supply can be filled through a CVS Caremark network pharmacy for in-network benefits. Up to 90-day prescription fills are only available. </s> |
<s>[INST] What will I pay for the Non-Preferred brand drugs prescription retail? [/INST] If you are a Network Provider (You will pay the least): Up to a 30-day supply $100 copayment. Up to a 90-day supply $200 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. You will pay the cost of the prescription drug if it is less than the copayment.Certain brand name prescription drugs are not covered, check with CVS Caremark at www.caremark.com Prescription drugs do not have a deductible. If you fill the same prescription drugs in a 30-day supply quantity or less 3 times, you will pay 175% of the copayment on the 4th and consecutive fills. If you select a preferred or non-preferred brand drug when a generic is available, you pay the copayment plus the cost difference between generic and preferred or non-preferred brand. Some prescription drugs require preauthorization. Up to a 30-day supply can be filled through a CVS Caremark network pharmacy for in-network benefits. Up to 90-day prescription fills are only available. </s> |
<s>[INST] What will I pay for the Non-Preferred brand drugs prescription mail order? [/INST] If you are a Network Provider (You will pay the least): Up to a 90-day supply $200 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. You will pay the cost of the prescription drug if it is less than the copayment.Certain brand name prescription drugs are not covered, check with CVS Caremark at www.caremark.com Prescription drugs do not have a deductible. If you fill the same prescription drugs in a 30-day supply quantity or less 3 times, you will pay 175% of the copayment on the 4th and consecutive fills. If you select a preferred or non-preferred brand drug when a generic is available, you pay the copayment plus the cost difference between generic and preferred or non-preferred brand. Some prescription drugs require preauthorization. Up to a 30-day supply can be filled through a CVS Caremark network pharmacy for in-network benefits. Up to 90-day prescription fills are only available. </s> |
<s>[INST] What will I pay for the Speciality drugs prescription of retail Generic? [/INST] If you are a Network Provider (You will pay the least): Up to a 30-day supply $20 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. You will pay the cost of the prescription drug if it is less than the copayment. Certain brand name prescription drugs are not covered, check with CVS Caremark at www.caremark.com Prescription drugs do not have a deductible. If you fill the same prescription drugs in a 30-day supply quantity or less 3 times, you will pay 175% of the copayment on the 4th and consecutive fills. If you select a preferred or non-preferred brand drug when a generic is available, you pay the copayment plus the cost difference between generic and preferred or non-preferred brand. Some prescription drugs require preauthorization. Up to a 30-day supply can be filled through a CVS Caremark network pharmacy for in-network benefits. Up to 90-day prescription fills are only available. Specialty drugs must be purchased from CVS Specialty Pharmacy. Specialty drugs are NOT available in 90-day supply quantities when certain clinical rules or quantity restrictions apply. </s> |
<s>[INST] What will I pay for the Speciality drugs prescription of mail order Generic? [/INST] If you are a Network Provider (You will pay the least): Up to a 90-day supply $40 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. You will pay the cost of the prescription drug if it is less than the copayment. Certain brand name prescription drugs are not covered, check with CVS Caremark at www.caremark.com Prescription drugs do not have a deductible. If you fill the same prescription drugs in a 30-day supply quantity or less 3 times, you will pay 175% of the copayment on the 4th and consecutive fills. If you select a preferred or non-preferred brand drug when a generic is available, you pay the copayment plus the cost difference between generic and preferred or non-preferred brand. Some prescription drugs require preauthorization. Up to a 30-day supply can be filled through a CVS Caremark network pharmacy for in-network benefits. Up to 90-day prescription fills are only available. Specialty drugs must be purchased from CVS Specialty Pharmacy. Specialty drugs are NOT available in 90-day supply quantities when certain clinical rules or quantity restrictions apply. </s> |
<s>[INST] What will I pay for the Speciality drugs prescription of retail Preferred Brand? [/INST] If you are a Network Provider (You will pay the least): Up to a 30-day supply $50 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. You will pay the cost of the prescription drug if it is less than the copayment. Certain brand name prescription drugs are not covered, check with CVS Caremark at www.caremark.com Prescription drugs do not have a deductible. If you fill the same prescription drugs in a 30-day supply quantity or less 3 times, you will pay 175% of the copayment on the 4th and consecutive fills. If you select a preferred or non-preferred brand drug when a generic is available, you pay the copayment plus the cost difference between generic and preferred or non-preferred brand. Some prescription drugs require preauthorization. Up to a 30-day supply can be filled through a CVS Caremark network pharmacy for in-network benefits. Up to 90-day prescription fills are only available. Specialty drugs must be purchased from CVS Specialty Pharmacy. Specialty drugs are NOT available in 90-day supply quantities when certain clinical rules or quantity restrictions apply. </s> |
<s>[INST] What will I pay for the Speciality drugs prescription of mail order Preferred Brand? [/INST] If you are a Network Provider (You will pay the least): Up to a 90-day supply $100 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. You will pay the cost of the prescription drug if it is less than the copayment. Certain brand name prescription drugs are not covered, check with CVS Caremark at www.caremark.com Prescription drugs do not have a deductible. If you fill the same prescription drugs in a 30-day supply quantity or less 3 times, you will pay 175% of the copayment on the 4th and consecutive fills. If you select a preferred or non-preferred brand drug when a generic is available, you pay the copayment plus the cost difference between generic and preferred or non-preferred brand. Some prescription drugs require preauthorization. Up to a 30-day supply can be filled through a CVS Caremark network pharmacy for in-network benefits. Up to 90-day prescription fills are only available. Specialty drugs must be purchased from CVS Specialty Pharmacy. Specialty drugs are NOT available in 90-day supply quantities when certain clinical rules or quantity restrictions apply. </s> |
<s>[INST] What will I pay for the Speciality drugs prescription of retail Non-Preferred Brand? [/INST] If you are a Network Provider (You will pay the least): Up to a 30-day supply $100 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. You will pay the cost of the prescription drug if it is less than the copayment. Certain brand name prescription drugs are not covered, check with CVS Caremark at www.caremark.com Prescription drugs do not have a deductible. If you fill the same prescription drugs in a 30-day supply quantity or less 3 times, you will pay 175% of the copayment on the 4th and consecutive fills. If you select a preferred or non-preferred brand drug when a generic is available, you pay the copayment plus the cost difference between generic and preferred or non-preferred brand. Some prescription drugs require preauthorization. Up to a 30-day supply can be filled through a CVS Caremark network pharmacy for in-network benefits. Up to 90-day prescription fills are only available. Specialty drugs must be purchased from CVS Specialty Pharmacy. Specialty drugs are NOT available in 90-day supply quantities when certain clinical rules or quantity restrictions apply. </s> |
<s>[INST] What will I pay for the Speciality drugs prescription of mail order Non-Preferred Brand? [/INST] If you are a Network Provider (You will pay the least): Up to a 90-day supply $200 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. You will pay the cost of the prescription drug if it is less than the copayment. Certain brand name prescription drugs are not covered, check with CVS Caremark at www.caremark.com Prescription drugs do not have a deductible. If you fill the same prescription drugs in a 30-day supply quantity or less 3 times, you will pay 175% of the copayment on the 4th and consecutive fills. If you select a preferred or non-preferred brand drug when a generic is available, you pay the copayment plus the cost difference between generic and preferred or non-preferred brand. Some prescription drugs require preauthorization. Up to a 30-day supply can be filled through a CVS Caremark network pharmacy for in-network benefits. Up to 90-day prescription fills are only available. Specialty drugs must be purchased from CVS Specialty Pharmacy. Specialty drugs are NOT available in 90-day supply quantities when certain clinical rules or quantity restrictions apply. </s> |
<s>[INST] Which services may I need If I have outpatient surgery? [/INST] 1. Facility fee (e.g., freestanding day surgicenter) 2. Physician/surgeon fees </s> |
<s>[INST] What will I pay for the Facility fee if I have outpatient surgery? [/INST] If you are a Network Provider (You will pay the least): $300 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. Outpatient surgery completed in a doctor’s office will only have the Physician/surgeon fees and no facility fee. </s> |
<s>[INST] What will I pay for the Physician/surgeon fees if I have outpatient surgery? [/INST] If you are a Network Provider (You will pay the least): $50 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. No Limitations, Exceptions, & Other Important Information. </s> |
<s>[INST] Which services may I need If I need immediate medical attention? [/INST] 1. Emergency room care 2. Emergency medical transportation 3. Urgent care </s> |
<s>[INST] What will I pay for the Emergency room care if I need immediate medical attention? [/INST] If you are a Network Provider (You will pay the least): $300 copayment. If you are Out-of-Network Provider (You will pay the most): $300 copayment. $300 copayment is waived if you’re admitted to hospital. $300 copayment, plus 40% coinsurance for non-emergency </s> |
<s>[INST] What will I pay for the Emergency medical transportation if I need immediate medical attention? [/INST] If you are a Network Provider (You will pay the least): No cost to you. If you are Out-of-Network Provider (You will pay the most): No cost to you. No Limitations, Exceptions, & Other Important Information. </s> |
<s>[INST] What will I pay for the Urgent Care if I need immediate medical attention? [/INST] If you are a Network Provider (You will pay the least): $75 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. No Limitations, Exceptions, & Other Important Information. </s> |
<s>[INST] Which services may I need If I have a hospital stay? [/INST] 1. Facility fee (e.g., hospital room) 2. Physician/surgeon fees </s> |
<s>[INST] What will I pay for Facility fee if I have a hospital stay? [/INST] If you are a Network Provider (You will pay the least): $500 copayment per day. If you are Out-of-Network Provider (You will pay the most): Not covered. Inpatient requires precertification. $1,500 maximum per stay </s> |
<s>[INST] What will I pay for Physician/surgeon fees if I have a hospital stay? [/INST] If you are a Network Provider (You will pay the least): $50 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. No Limitations, Exceptions, & Other Important Information. </s> |
<s>[INST] Which services may I need if I need mental health, behavioral health, or substance abuse services? [/INST] 1. Outpatient services for mental health, substance abuse 2. Outpatient services for family therapy or couples therapy 3. Inpatient services for mental health, substance abuse. </s> |
<s>[INST] What will I pay for Outpatient services for mental health, substance abuse? [/INST] If you are a Network Provider (You will pay the least): $15 or $50 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. If PCP office visit, PCP copayment would apply. If Specialist office visit, Specialist copayment would apply. </s> |
<s>[INST] What will I pay for Outpatient services for family therapy or couples therapy? [/INST] If you are a Network Provider (You will pay the least): $15 or $50 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. If PCP office visit, PCP copayment would apply. If Specialist office visit, Specialist copayment would apply. </s> |
<s>[INST] What will I pay for Inpatient services for mental health, substance abuse? [/INST] If you are a Network Provider (You will pay the least): $500 copayment per day. If you are Out-of-Network Provider (You will pay the most): Not covered. Inpatient requires precertification. $1,500 maximum per stay. </s> |
<s>[INST] What will I pay for Employee Assistance Program (EAP)? [/INST] If you are a Network Provider (You will pay the least): 4 visits per issue, no cost to you. If you are Out-of-Network Provider (You will pay the most): Not covered. Inpatient requires precertification. $1,500 maximum per stay. The EAP network of providers may be different than the network of your network administrators; check with your network administrator’s provider network to ensure the EAP provider participates in both networks. See SPD for details. </s> |
<s>[INST] Which services may I need if I am pregnant (you, your spouse, or dependent daughter)? [/INST] 1. Office, routine prenatal care 2. Birth/delivery professional services 3. Birth/delivery facility services </s> |
<s>[INST] What will I pay for Office, routine prenatal care if I am pregnant (you, your spouse, or dependent daughter)? [/INST] If you are a Network Provider (You will pay the least): $0 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. Non-routine prenatal care see SPD for details. </s> |
<s>[INST] What will I pay for Birth/delivery professional services if I am pregnant (you, your spouse, or dependent daughter)? [/INST] If you are a Network Provider (You will pay the least): $50 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. No Limitations, Exceptions, & Other Important Information. </s> |
<s>[INST] What will I pay for Birth/delivery professional services if I am pregnant (you, your spouse, or dependent daughter)? [/INST] If you are a Network Provider (You will pay the least): $500 copayment. If you are Out-of-Network Provider (You will pay the most): Not covered. No Limitations, Exceptions, & Other Important Information. </s> |
<s>[INST] Which services may I need if I need help recovering or have other special health needs? [/INST] 1. Home health care 2. Rehabilitation services 3. Habilitation services 4. Skilled nursing care 5. Durable medical equipment 6. Hospice services </s> |
<s>[INST] What will I pay for Home health care if I need help recovering or have other special health needs? [/INST] If you are a Network Provider (You will pay the least): $50 copayment per day. If you are Out-of-Network Provider (You will pay the most): Not covered. Maximum of 40 services, $500 maximum per episode. </s> |
<s>[INST] What will I pay for Rehabilitation services if I need help recovering or have other special health needs? [/INST] If you are a Network Provider (You will pay the least): $50 copayment per visit. If you are Out-of-Network Provider (You will pay the most): Not covered. $500 maximum per injury/illness </s> |
<s>[INST] What will I pay for Habilitation services if I need help recovering or have other special health needs? [/INST] If you are a Network Provider (You will pay the least): Not covered. If you are Out-of-Network Provider (You will pay the most): Not covered. This plan does not cover this service, see SPD. </s> |
<s>[INST] What will I pay for Skilled nursing care if I need help recovering or have other special health needs? [/INST] If you are a Network Provider (You will pay the least): $50 copayment per day. If you are Out-of-Network Provider (You will pay the most): Not covered. Maximum benefit is 60 days per illness or injury, $500 maximum per injury, Within 15 days of hospitalization. </s> |
<s>[INST] What will I pay for Durable medical equipment if I need help recovering or have other special health needs? [/INST] If you are a Network Provider (You will pay the least): 20% coinsurance. If you are Out-of-Network Provider (You will pay the most): Not covered. Dollar and quantity limits may apply, see SPD. </s> |
<s>[INST] What will I pay for Hospice services if I need help recovering or have other special health needs? [/INST] If you are a Network Provider (You will pay the least): $50 copayment per day . If you are Out-of-Network Provider (You will pay the most): Not covered. $500 maximum per episode. </s> |
<s>[INST] Which services may I need if my child needs dental or eye care? [/INST] 1. Children’s eye exam 2. Children’s glasses 3. Children’s dental check-up </s> |
<s>[INST] What will I pay for Children’s eye exam if my child needs eye care? [/INST] If you are a Network Provider or you are Out-of-Network Provider: Not covered by Medical. Paid under Vision Benefit, if you elected it. </s> |
<s>[INST] What will I pay for Children’s glasses if my child needs eye care? [/INST] If you are a Network Provider or you are Out-of-Network Provider: Not covered by Medical. Paid under Vision Benefit, if you elected it. </s> |
<s>[INST] What will I pay for Children’s dental check-up if my child needs dental care? [/INST] If you are a Network Provider or you are Out-of-Network Provider: Not covered by Medical. Paid under Dental Benefit, if you elected it. </s> |
<s>[INST] What are my rights to continue coverage? [/INST] There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: US Department of Labor Employee Benefits Security Administration (1-866-444-EBSA [3272]) or American Airlines Benefits Service Center at 1-888-860-6178. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318-2596. </s> |
<s>[INST] What are my Grievance and Appeals Rights? [/INST] There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: American Airlines, Inc. Benefits Service Center at 1-888-860-6178, or the US Department of Labor at 1-866-487-2365. </s> |
<s>[INST] Does this plan provide Minimum Essential Coverage? [/INST] YES, If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. </s> |
<s>[INST] What are language access services? [/INST] Spanish (Español): Para obtener asistencia en Español, llame al 1-888-860-6178, Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-860-6178 Chinese (中文): 如果需要中文的帮助，请拨打这个号码1-888-860-6178, Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-888-860-6178 </s> |
<s>[INST] What types of disability benefits does the Company provide for eligible Ground Employees? [/INST] The Company provides short-term disability benefits for eligible Ground Employees. </s> |
<s>[INST] Who is eligible for Optional-Short-Term Disability (OSTD) Insurance? [/INST] OSTD Insurance is available for certain TWU-represented employees and employees represented by the Communications Workers of America, AFL-CIO, CLC, IBT. </s> |
<s>[INST] Are there additional details available for the mentioned coverages? [/INST] Yes, additional details on these coverages can be found in supplemental insurance certificates. </s> |
<s>[INST] How are supplemental insurance certificates related to the SPD (Summary Plan Description)? [/INST] Supplemental insurance certificates are incorporated and are a part of the SPD. </s> |
<s>[INST] Where can one find additional details on Disability benefits? [/INST] Additional details on Disability benefits may be contained in supplemental insurance certificates. </s> |
<s>[INST] What is the contact information for MetLife regarding Short-Term Disability benefits? [/INST] contact MetLife at 1-888-533-6287 for more information on Short-Term Disability benefits or visit https://online.metlife.com/edge/web/public/benefits </s> |
<s>[INST] Who is eligible for the Optional Short-Term Disability (OSTD) Insurance benefit? [/INST] The OSTD Insurance benefit applies to certain TWU-represented employees and employees represented by the Communication Workers of America, AFL-CIO, CLC, IBT. Dependents are not eligible for this benefit. </s> |
<s>[INST] What does the Company offer for salary continuance during disabilities, and why might a gap occur in this coverage? [/INST] The Company offers a certain amount of paid sick time for salary continuance during disabilities. However, a gap may occur between the time accrued sick pay ends and Long-Term Disability (LTD) benefits begin. (Note that Long-Term Disability benefits are not part of this Plan.) </s> |
<s>[INST] In the case of a gap between accrued sick pay and the start of Long-Term Disability (LTD) benefits, what alternative is offered by the Company? [/INST] In such cases, the Company offers Optional Short-Term Disability (OSTD) Insurance benefits to provide income protection until LTD benefits begin. </s> |
<s>[INST] How does OSTD Insurance benefit individuals who are unable to work due to a non-work-related disability? [/INST] OSTD Insurance benefits replace a portion of your salary when you are unable to work as a result of a non-work-related disability. </s> |
<s>[INST] What should individuals consider before electing OSTD Insurance coverage? [/INST] Before electing OSTD Insurance coverage, individuals should consider their accrued sick time because OSTD Insurance benefits are not payable until all accrued sick pay is used. </s> |
<s>[INST] How is the cost of OSTD Insurance collected? [/INST] The cost of OSTD Insurance is collected through after-tax payroll deductions. </s> |
<s>[INST] How long does the enrollment in OSTD Insurance remain in effect if an individual chooses to enroll? [/INST] If an individual enrolls, the selection remains in effect for two calendar years. </s> |
<s>[INST] What is required if an individual decides to enroll in OSTD Insurance later after initially choosing not to enroll? [/INST] If an individual chooses not to enroll when first eligible and decides to enroll later, Proof of Good Health is required. OSTD Insurance will not become effective until the individual is actively at work, and a payroll deduction has been taken. </s> |
<s>[INST] What action must individuals take if they are unable to work their normal work schedule for any reason, regardless of OSTD Insurance benefits? [/INST] If individuals are unable to work their normal work schedule for any reason, they must address their work status with their supervisor. This is true regardless of whether they receive OSTD Insurance benefits. </s> |
<s>[INST] How does one qualify for Optional Short-Term Disability (OSTD) Insurance benefits? [/INST] To qualify for OSTD Insurance benefits, an individual must be considered "totally disabled." This means they are not gainfully employed in any job for wage or profit and are unable to perform major and substantial duties pertaining to their own occupation due to sickness or accidental bodily injury. </s> |
<s>[INST] What is the requirement for receiving Appropriate Care and Treatment during a disability? [/INST] Appropriate Care and Treatment, required during a disability, means medical care and treatment that is given by a Physician whose medical training and clinical specialty are appropriate for treating the disability. It should also be consistent with relevant guidelines of national medical research, health care coverage organizations, and governmental agencies, consistent with a Physician's diagnosis of the disability, and intended to maximize medical and functional improvement. </s> |
<s>[INST] What criteria determine whether an individual is considered "totally disabled" for OSTD Insurance benefits? [/INST] An individual is considered "totally disabled" for OSTD Insurance benefits if they are not gainfully employed in any type of job for wage or profit and are unable to perform major and substantial duties pertaining to their own occupation due to sickness or accidental bodily injury. </s> |
<s>[INST] Who should provide Appropriate Care and Treatment for the qualification of OSTD Insurance benefits? [/INST] Appropriate Care and Treatment for the qualification of OSTD Insurance benefits should be provided by a Physician whose medical training and clinical specialty are appropriate for treating the disability. </s> |
<s>[INST] How does the Company's approval of sickness or injury leave of absence relate to disability benefit determination? [/INST] The Company's approval of sickness or injury leave of absence is independent of disability benefit determination. It should not be construed as validation of a disability claim or any guarantee of benefits payable for the disability claim. </s> |
<s>[INST] What is the purpose of the Optional Short-Term Disability (OSTD) Insurance benefit, and who is the insurance provider? [/INST] The OSTD Insurance benefit is designed to supplement other similar benefits and is insured through MetLife. It aims to provide 50% of the "adjusted monthly salary" for up to 26 weeks. The maximum covered salary is $200,000. </s> |
<s>[INST] How is the "adjusted monthly salary" calculated for regular, full-time employees enrolled in OSTD Insurance? [/INST] For regular, full-time employees, "adjusted monthly salary" is defined as the annual base salary or annualized hourly pay, plus skill and license premiums, and market differentials. It excludes profit sharing, bonus, overtime, or incentive pay. </s> |
<s>[INST] What determines the "adjusted monthly salary" for converted and part-time employees covered by OSTD Insurance? [/INST] For converted and part-time employees, the "adjusted monthly salary" is based on the average weekly earnings for the last six months. </s> |
<s>[INST] How is the OSTD Insurance benefit adjusted in cases of income from other sources or earnings during the Return-to-Work Program? [/INST] The OSTD Insurance benefit is adjusted to reflect income from other sources, and any work earnings during the Return-to-Work Program that cause total income from all sources to exceed 100% of pre-disability earnings. </s> |
<s>[INST] If enrolled in Long-Term Disability (LTD) coverage, what benefits are received in conjunction with OSTD Insurance? [/INST] Enrolled individuals receive the full OSTD Insurance benefit. Additionally, a minimum benefit from LTD coverage is provided, starting the later of four months from the date of disability or when sick pay is exhausted. After exhausting 26 weeks of OSTD Insurance, the full LTD benefit becomes payable. (Note: Long-Term Disability benefits are not part of this Plan.) </s> |
<s>[INST] Under what circumstances may OSTD Insurance benefits be limited? [/INST] OSTD Insurance benefits may be limited in cases where employees are based in California, Hawaii, New Jersey, New York, Rhode Island, or Puerto Rico and may be eligible for state disability benefits. In California, Hawaii, and Rhode Island, employees must apply directly to the state for benefits. Additionally, individuals with a significant number of unused sick days cannot collect OSTD Insurance until those days are exhausted. </s> |
<s>[INST] Is the OSTD Insurance benefit taxable income? [/INST] No, the OSTD Insurance benefits are not taxable income because individuals pay for this coverage with after-tax contributions. </s> |
<s>[INST] How are Optional Short-Term Disability (OSTD) Insurance benefits affected by periodic loss of income payments under no-fault auto laws? [/INST] OSTD Insurance benefits are reduced if individuals are either receiving periodic loss of income payments under no-fault auto laws or are entitled to receive these benefits upon timely filing of respective claims. Such payments will offset the OSTD Insurance benefit. </s> |
<s>[INST] What is the impact on OSTD Insurance benefits in the presence of recovery amounts from third-party claims, including future earnings? [/INST] OSTD Insurance benefits may be affected by recovery amounts received from loss of income due to claims against a third party by judgment, settlement, or otherwise, including future earnings. These recovery amounts may offset the OSTD Insurance benefit. </s> |
<s>[INST] Can you provide examples of situations where OSTD Insurance benefits may be reduced due to benefits from other sources? [/INST] OSTD Insurance benefits may be reduced if individuals are receiving periodic loss of income payments under no-fault auto laws or recovery amounts from third-party claims, including future earnings. In both cases, these benefits from other sources will offset the OSTD Insurance benefit. </s> |
<s>[INST] When OSTD Insurance Benefits Begin? [/INST] Provided you qualify, OSTD Insurance benefits are payable on the eighth day of disability or when your accrued paid sick time is exhausted, whichever occurs later. If you are collecting vacation pay when OSTD Insurance benefits become payable, OSTD Insurance benefits will not begin until your vacation pay ends. </s> |
<s>[INST] Is there a limit to the number of times an individual can receive Optional Short-Term Disability (OSTD) Insurance benefits for different periods of disability? [/INST] No, there is no limit to the number of times an individual may receive OSTD Insurance benefits for different periods of disability. </s> |
<s>[INST] How are successive periods of disability treated if separated by less than 60 days of full-time active work? [/INST] Successive periods of disability separated by less than 60 days of full-time active work are considered a single period of disability. Such disabilities will be considered part of the original disability. </s> |
<s>[INST] What aspects of the original disability are applied to successive periods of disability with less than 60 days of full-time active work in between? [/INST] MetLife will use the same pre-disability earnings and apply the same terms, provisions, and conditions that were used for the original disability in the case of successive periods of disability separated by less than 60 days of full-time active work. </s> |
<s>[INST] How does the treatment of successive periods of disability benefit the individual in case of a recurrence due to the same or related sickness or accidental injury? [/INST] If an individual becomes disabled again due to the same or related sickness or accidental injury, they will not be required to meet a new elimination period. This is beneficial as the original elimination period will still apply. </s> |
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