FHLAC Contract

FHLAC Contract Arrangements

 

The Plan Administrator has the sole discretionary authority to determine eligibility for benefits and to construe the terms of this plan. The Teamsters Local 170 Health and Welfare Benefit Plan is responsible for paying the costs of all covered services and charges incurred for services and benefits described in this document. FHLAC is not responsible for any services or charges that are not paid for by the plan.

Changes in your coverage

All enrollment changes or any additions or changes to coverage type are allowed only when they conform to underwriting guidelines. The Plan Administrator reserves the right to change, alter, amend or terminate the plan, including the benefits available to you under this plan at any time, for any reason.

We will notify your Plan Administrator of any changes to your benefits under this plan. The notice will include the effective date of the change. The plan will be changed whether or not you receive the notice.

If the plan is terminated, any eligible claims incurred before the date of termination will be paid to the extent assets held by Teamsters Local 170 Health and Welfare Fund are available (or according to the insurance contract for coverage), if submitted to FHLAC within a reasonable period of time, as established by the Plan Administrator. Any claims incurred after the date of termination will not be considered for payment.

Notices

When FHLAC sends you a notice, it will be mailed to your most recent address on file. If your name and/or mailing address changes, notify FHLAC and the Plan Administrator. Be sure to provide your old name and address as well as the new information.

FHLAC contracting arrangements

FHLAC contracts with individual physicians, medical groups, hospitals and ancillary providers to provide care to members. FHLAC negotiates with providers to agree upon a contracted payment rate. The providers then accept that payment for their services. When you obtain a covered service, the only payment that a provider will collect from you for a covered service is the copayment, coinsurance or deductible amounts shown in this Member Handbook, or in any applicable schedules of benefits or addenda.

When your provider no longer has a contract with us

FHLAC cannot guarantee that any one physician, hospital or other provider will be available and/or remain under contract with us. FHLAC reserves the right at any time to end our contract with your PCP or with any other plan provider who may be furnishing you with treatment. If this occurs, FHLAC will generally no longer pay for services provided to you by that provider, except in the circumstances listed below.

If the provider whose contract FHLAC is ending is your PCP, FHLAC will notify you in writing at least 30 days prior to the date of the end of his or her contract, except where the contract has been ended for reasons involving fraud, patient safety or quality of care.

If your PCP ends his or her contract with us, FHLAC will notify you of the change either 30 days prior to the date the contract ends, or as soon as FHLAC is notified of the termination, whichever is later. If our contract with your PCP ends, you will be required to choose a new PCP.

FHLAC will also notify you if you are receiving regular care from a specialist, and that specialist will no longer be under contract with us.

FHLAC will continue to pay for services of your provider after our contract with the provider ends in the following circumstances only:

  • If our contract with your PCP ends, you may continue to receive treatment from that provider for 30 days beyond the end of the contract.
  • If you are in the second or third trimester of pregnancy when our contract with a provider from whom you are receiving pregnancy-related treatment ends, you may continue to receive treatment from that provider through your postpartum period.
  • If you are terminally ill and our contract with a provider from whom you are receiving treatment related to that illness ends, you may continue to receive treatment from that provider.

In all cases, the provider must agree to accept reimbursement for services at the rates in effect when our contract with the provider ended, and to adhere to our quality assurance standards, and other policies and procedures such as referrals and prior authorization. You will be eligible for benefits as if the provider had remained under contract with us.

If your provider is no longer under contract with us, call Customer Service at 1-800-868-5200 (TTY users please call TRS Relay 711) for assistance in choosing a new provider or to request a provider directory.

You also can get provider information and choose a new PCP on our Web site fchp.org.

Continuation of services with a non-plan provider

Once you become a plan member, FHLAC will generally only pay for services that you receive from plan providers. However, there are some circumstances in which FHLAC will temporarily pay for services that you receive from a non-plan provider, if you had been receiving care from that provider prior to becoming a member:

  • If your prior primary care physician is not a participating provider in any health insurance plan that your plan sponsor offers, FHLAC will pay for services from that provider for 30 days from your effective date.
  • If you are receiving an ongoing course of treatment from a provider who is not a participating provider in any health insurance plan that your plan sponsor offers, FHLAC will pay for services from that provider for 30 days from your effective date.
  • If you are in the second or third trimester of pregnancy, and you are receiving services related to your pregnancy from a provider who is not a participating provider in any health insurance plan that your plan sponsor offers, FHLAC will pay for services from that provider through your postpartum period.
  • If you are terminally ill, and you are receiving ongoing treatment from a provider who is not a participating provider in any health insurance plan that your plan sponsor offers, FHLAC will pay for your services from that provider until your death.

In all cases, the provider must agree to accept reimbursement for services at our rates, and to adhere to our quality assurance standards, and other policies and procedures such as obtaining appropriate referrals and prior authorizations. You will be eligible for benefits as if the provider was under contract with us.

Responsibility for the acts of providers

The arrangement between the plan, plan providers and the plan facilities is that of independent contractors. They are not agents of FHLAC or of the Teamsters Local 170 Health and Welfare Benefit Plan. FHLAC is not liable for injuries or damages resulting from acts or omissions by them or by any other institution or person providing services to you. You should not rely on providers or facilities for any assurances or interpretation of plan policies or benefits. FHLAC will not interfere with the ordinary relationship between providers and their patients except in circumstances in which a provider does not comply with health plan policies.

If you are admitted to a hospital or other facility as an inpatient, or if you are an outpatient, you will be subject to all of that facility’s rules. This includes rules on admission, discharge and the availability of services.

If a provider recommends or provides a specific treatment, this does not necessarily make that treatment a covered benefit. Since plan providers are freely able to recommend treatment options without restraint from FHLAC, a physician referral or recommendation in and of itself does not guarantee that a referral or recommended treatment is a covered benefit or that the accepting provider is contracted with the plan, and does not obligate the plan to pay for the service. Services or supplies that are not described as covered in this Member Handbook, or that did not receive any necessary prior authorization from the plan, or that are not determined to be medically necessary, are not covered benefits.

Circumstances beyond our control

Under extraordinary circumstances that are beyond our control, FHLAC may have to delay your services, or we may be unable to provide them at all. FHLAC will not be liable for failing to provide, or for a delay in providing, services in the cases described below. FHLAC will, however, make a good faith effort to provide or arrange for services in these situations, limited by available facilities and personnel:

  • In the case of major natural disasters, epidemics or pandemics
  • In the case of a war, riot, civil insurrection or acts of terrorism