Definitions continued
To help you better understand your health plan, the Affordable Care Act (ACA) requires insurers and group health plans to provide a new way to show benefits and define health care industry terms. These required documents are called the Summary of Benefits and Coverage, or SBC. The goal of the SBC is to help you more easily compare health plans so you can choose the one that’s right for you. SBCs are provided in a standard format, which may only be different based on the specific benefits offered by each plan. The summary plan descriptions (SPDs) are important documents that tell participants what plans provide and how they operate in greater detail. They provide information on when an employee can begin to participate in a plan, how services and benefits are calculated, when and in what form benefits are paid, and how to file a claim for benefits. SPDs can be found on the Human Resources Intranet. If you are unable to print an SPD, please contact the Benefits Office at 516-367-5027 to obtain a free copy of an SPD. A freestanding facility is an outpatient, diagnostic, or ambulatory center or independent laboratory that performs services and submits claims as a freestanding entity and not as a hospital. An alternate facility is a healthcare facility that is not a hospital and that provides one or more of the following services on an outpatient basis, as permitted by law: surgical services; emergency health services; and/or rehabilitative, laboratory, diagnostic, or therapeutic services. An alternate facility may also provide mental health services or substance use disorder services on an outpatient basis or inpatient basis (for example, a residential treatment facility). A place of service that is owned by a hospital and provides services that are billed under the tax idenitifcation number of the hospital. Virtual care visits are interacting with a designated virtual visit network provider using live video, audio, and instant messaging to communicate with their patients remotely.
SBC: Summary of Benefit Coverage
SPD: Summary Plan Description
Freestanding Facility
Alternate Facility
Hospital-based services/facility
Virtual Care Visits
Benefit Eligibility
Eligibility Information As an employee working 30 hours or more per week, you and your eligible dependents qualify for Medical, Dental, Vision, and Life/ AD&D Insurance benefits. If your spouse or domestic partner has access to group coverage through his or her own employer, they are not eligible for CSHL medical/vision and/or dental benefits. Special enrollment rules apply if you are married to another CSHL employee or graduate student. Making Changes During the Year Generally you can only change your benefit elections during the annual benefits Open Enrollment period. A change is permitted when you experience any IRS Qualifying Life Event (QLE), such as marriage, divorce, birth, or adoption. You must notify Human Resources within 31 days of any QLE to make changes. Otherwise, you’ll have to wait until the next Open Enrollment period. Any changes you make to your benefit choices must be directly related to the QLE. Proof of the change will be required (example: a marriage license or birth certificate). When Coverage Ends All benefits end on your last day of work. However, under certain circumstances, you may continue your health care benefits through COBRA Insurance.
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