Teamsters Local 170 Health and Welfare Fund

FCHP Direct Care Member Handbook

FCHP Direct Care Member Handbook

 
Welcome!

Teamsters Local 170 Health and Welfare Fund has arranged to provide you with a comprehensive health care plan administered by Fallon Health & Life Assurance Company, Inc. (FHLAC). The Teamsters Local 170 Health and Welfare Benefit Plan (the plan) is designed to manage quality of care and control health care costs by taking advantage of strong provider contracts and the most current managed care practices.

This Member Handbook describes the services covered under this plan including any limitations and exclusions that may affect your rights to covered services, your copayments and claims procedures. Please read this Member Handbook carefully and keep it for future reference.

Teamsters Local 170 Health and Welfare Fund administers the plan, and has the right to make rules about eligibility for benefits and the level of benefits available. Teamsters Local 170 Health and Welfare Fund may amend the rules and benefits at any time. Teamsters Local 170 Health and Welfare Fund has the right to interpret the terms of this document and will interpret and apply its terms in situations not expressly addressed in this site. Teamsters Local 170 Health and Welfare Fund has delegated authority to FHLAC to help manage the plan.

If you have any questions about your coverage under this plan, please call Customer Service. Representatives are available Monday, Tuesday, Thursday, and Friday from 8 a.m. to 6 p.m. and Wednesday from 10 a.m. to 6 p.m., at 1-800-868-5200 (TTY users please call TRS Relay 711).

About this Member Handbook

This Member Handbook is effective January 1, 2014. There are no waiting periods or pre-existing condition limitations under this contract. You may use the services described here beginning on January 1, 2014, or on your effective date, whichever comes later. This Member Handbook details the benefits and services that the plan covers, explains our policies and procedures, and contains other information such as:

  • Definitions of important terms
  • Important points to remember
  • Our customer service capabilities
  • The FCHP Direct Care service area
  • The role of your primary care provider (PCP)
  • Referral and prior authorization procedures
  • Your rights and responsibilities
  • Types of coverage available
  • Claims procedures
  • Additional contract provisions
  • Covered services
  • Exclusions

Your Schedule of Benefits lists your costs for covered services. If you belong to a group that has arranged for additional or different benefits, you can find that information in the Schedule of Benefits as well. The information contained in a Schedule of Benefits replaces any information in this Member Handbook that conflicts with it. If we need to update or change your handbook, we will send to you, or in the case of a group policy, to the group representative, an amendment. Please also be advised that this Member Handbook and any amendments to it are available on our Web site fchp.org.

It is important to keep this and your Schedule of Benefits, along with any addenda or amendments, in a place for easy reference.

Understanding your health care coverage

This plan, administered by Fallon Health & Life Assurance Co., Inc. (FHLAC) is a health maintenance organization that provides health care coverage for its members through a network of health care professionals and hospitals. Fallon Health & Life Assurance Company is a fully-owned subsidiary of Fallon Community Health Plan, a federally qualified health plan. However, this group welfare benefit plan, entered into at the request of Teamsters Local 170 Health and Welfare Fund, may or may not meet all of the specific legal requirements for federal qualification and should not be considered a federally qualified line of business. Our administrative offices are located at Chestnut Place, 10 Chestnut St., Worcester, MA 01608.

This plan requires you to use specific physicians, hospitals and other providers that are part of your plan. Understanding how your health plan works is important. For one thing, it helps you know what to expect. The following information highlights the most important points about how we work to ensure you receive quality care and services.

Important points to remember:

  • The FCHP Direct Care network includes plan providers in Berkshire, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk, and Worcester Counties. In order for you to receive coverage for most services, care must be coordinated by your primary care provider (PCP) and administered by a plan provider.
  • When you join this plan, you choose a primary care provider (PCP) who coordinates your health care. You will not require a referral to see a Reliant Medical Group specialist if you have a Reliant Medical Group PCP.
  • For other covered services, you should obtain a referral from your PCP, and in some cases, your physician will obtain prior authorization from the health plan.
  • FHLAC maintains a formulary, or a list of medications, approved for coverage.
  • FHLAC requires prior authorization for certain services and the site of where those services will be provided.

Please note: If a physician or other health care provider discusses a treatment option with you, this does not necessarily make that treatment a covered service. Physicians and other health care providers are freely able to discuss treatment options without restraint from FHLAC. However, services or supplies that are not described as covered in the Description of benefits section of this Member Handbook and that do not receive the necessary prior authorization from FHLAC are not covered services. Services that are not medically necessary are not covered services. Services and supplies you receive from providers who are not in the FCHP Direct Care network are not covered services, unless you received prior authorization from FHLAC to go to that provider. Unauthorized services will be the financial responsibility of the member.

Your membership card
When you enrolled in this plan, FHLAC mailed a membership card for each covered family member. Please carry the card with you at all times. Providers may ask you for your membership card when you seek medical care, or you may be asked for your card when you fill a prescription at a network pharmacy.

You should receive your card within 30 days of the date that FHLAC receives and verifies your enrollment request. If you do not receive a card, or if you lose or damage your card, contact Customer Service to request a new card.

Notifying us of changes
Contact Customer Service to report any changes in your name, address, phone number, primary care providers, number and status of dependents or any other pertinent information. If there is a change to your family status that would require a change to your contract type (for example, you have an individual contract, but you marry or have children), you should notify the Plan Administrator within 30 days of the qualifying event, and they will notify FHLAC.

Whenever you change to a new primary care provider, FHLAC recommends that you have your medical records transferred to your new provider. Please note that FHLAC does not cover any cost associated with having your records copied.