Active Eligibility FAQs

What are the requirements to be eligible for active health coverage?

In order for Active Members to be eligible for Health Benefits, you must be in the eligible class and have the required amount of hours in the qualifying work periods:

To be eligible for May 1st:

600 hours between August 1st through January 31st, or

1200 hours between February 1st through January 31st

 

To be eligible for November 1st:

600 hours between February 1st through July 31st,

1200 hours between August 1st through July 31st

 

Please be sure to check your hours regularly for discrepancies. You can view them on the Work Record Report that is mailed out quarterly. If hours are not reported on your behalf please click here to have the Fund Office review your hours.

 

If I or one of my dependents become ineligible for Health Coverage, does the Fund Office have any coverage we may elect to enroll in?

Yes, you may elect to enroll in COBRA coverage. COBRA information is sent to any eligible member or dependent who is losing Health Coverage. You may elect to enroll in the COBRA coverage up to 18 months if you are losing eligibility due to lack of hours. A dependent may elect COBRA for up to 36 months in the event of a divorce, the death of the Member, or if a dependent child turns 26 and is no longer eligible to be covered under the Member.

I am losing my coverage. What are my options?

COBRA is sent to any Participant who is losing their coverage, as well as any Qualifying Beneficiary. You may also elect to purchase coverage through the Health Insurance Exchange at https://www.healthcare.gov.

What is the cost of COBRA Coverage?

The type of coverage you elect will determine your cost for COBRA coverage. For additional information, please contact the Fund Office at (215) 568-0430 and ask for the Medical Department.

How long does COBRA coverage last?

18 or 36 months, depending on the reason for loss of coverage.

Medical Coverage FAQs

Are Doctor and Specialist visits covered?

All Primary Care and Specialist visits at a Participating Independence Administrator's (IA) provider are covered at 90% of IA's allowed amount, leaving you responsible for only the 10% coinsurance. All testing and procedures done during your visit will also be covered at 90% of IA's allowed amount. Please visit www.MyIBXTPABenefits.com for a list of Participating Providers.

What is the difference between a deductible, a co-pay, and coinsurance?

A deductible is the initial amount of money you must pay for health care services before your insurance starts to pay for covered services. For all In Network Claims through Independence Administrators or Mental Health Consultants, your coverage does not have a deductible.

A co-pay is a fixed dollar amount you are required to pay for health care services. For example, if you visit a Participating Chiropractor, the copay is $5.

Coinsurance is the set percentage of the allowed amount you are required to pay for health care services. Currently, the coinsurance amount of an office visit through a Participating Independence Administrator provider is 10%.

Is there an "Out-of-Pocket Maximum," and what does that mean?

Out-of-Pocket Max means the total amount of money you can spend of your pocket in a Plan Year (May 1st through April 30th). The out-of-pocket maximum for In-Network Services through Independence Administrators and MHC is $2,000.00 for an individual and $4,000.00 for a family.

Please note, there is a separate out-of-pocket maximum for Out of Network Services through IBX and MHC is $15,000.00 for an individual and $30,000.00 for a family after the Out of Network Deductible is met.

 

What is the Out-of-Network Out-of-Pocket?

If you utilize Out-of-Network Facilities, after the deductible ($10,000.00 individual/$20,000.00 family) is met, your Out of Pocket Maximum is a combination of your copays and coinsurances with a limit of $15,000.00 for individuals and $30,000.00 for family.

Can I use an Urgent Care Facility, or a Minute Clinic at a pharmacy?

Yes, you may utilize an Urgent Care Facility or a Minute Clinic at a pharmacy as long as they are participating with Independence Administrators (IA). Urgent Care visits and all testing and procedures are covered at 90% of IA's allowed amount. Please visit www.MyIBXTPABenefits.com for a list of Participating Providers.

Is there a Deductible?

For In-Network claims processed through Independence Administrators Personal Choice (IA) and Mental Health Consultants (MHC) there is currently NO DEDUCTIBLE.

For Out of Network claims processed through Independence Administrators Personal Choice (IA) and Mental Health Consultants (MHC) there is a $10,000.00 deductible for an individual and a $20,000.00 deductible for a family. If you are seeking services and the provider is Out of Network, contact IA or MHC and ask for alternative physicians.

 

Where can I find a list of Participating Independence Administrator's Providers?

You may find a list of Participating Providers for Health Care Professionals on the Independence Administrators Website at www.MyIBXTPABenefits.com.  

You may also contact Independent Administrators directly at 1-833-810-BLUE.

What is considered Preventative Care?

Preventative Care encompasses procedures such as: Vaccinations, Immunizations, and Wellness Visits. Preventative Care eligibility will be determined by your Primary Care Physician based on medical necessity and your unique individual situation. All preventative care is covered at 100%.

Where do I send my Independence Administrators Claims to?

If you visit a Independence Administrator's Participating Provider, there shouldn’t be any claims forms for you to submit. As long as you are supplying your Independence Administrators Card, the provider will submit the claim for you.

Mental Health FAQs

What does Individual Counseling cost?

If you visit a Psychologist, Psychiatrist, or Counselor from Mental Health Consultants (MHC) Network of Participating Providers, you will be responsible for 10% of the charges. However, if you visit a Non-Participating Provider, you will be responsible for all charges until you reach your annual $10,000 (Individual) or $20,000 (Family) Deductible.

I want to go out of state for in-patient treatment. What are my options?

Mental Health Consultants (MHC) offers an extensive list of Participating Behavioral Health Providers, and Treatment Facilities for Mental Health & Substance Abuse. If you are considering obtaining any type of Behavioral Health Services, including in-patient facility stays, it is imperative you contact MHC at 1-800-255-3081 to discuss which facilities and locations are best for your course of treatment. Failing to choose an in-network facility will result in a $10,000 (Individual) or $20,000 (Family) Deductible, in addition to a 90/10% Coinsurance.

What is the out-of-network deductible?

Any out of network treatment / counseling has a $10,000 deductible per individual or $20,000 deductible per family before payment is made. If you have chosen a provider who is out of network, please contact Mental Health Consultants (MHC) for more assistance

Heart Scan FAQs

How do I schedule a heart scan?

Submit the online authorization request form or call the Fund office at 215-568-0430 to obtain your authorization number.

Than call the Temple Access Center at 215-707-8800, Monday-Friday between 8:00 am - 6:00 pm, to set-up your appointment date and time.

When/where is the scan performed?

Temple University Hospital - 3509 N. Broad Street (enter on Tioga), 4th Floor, Boyer Pavilion, Philadelphia, PA 19140.

Monday - Friday* 8:00 am - 4:00 pm

*Some day-time Saturdays are offered for convenience. 

Can I get a heart scan if I am under the age requirement?

Yes, you will need a Letter of Medical Necessity from your Primary Care Physician.