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FREQUENTLY ASKED QUESTIONS ABOUT NMPSIA ENROLLMENT RULES
Q. If I decline medical coverage during my 31-day window of opportunity, may I enroll to NMPSIA medical coverage at a later date? A. If you do not turn in your application during your 31-day window of opportunity, you may enroll late to any of the medical plans. Late entrants are subjected to a maximum 18-month preexisting conditions limitation period. You may have other opportunities to enroll within 31 days from involuntarily losing other coverage or within 31 days from the occurrence of a Federal HIPAA special event.
Q. How often does NMPSIA have an open enrollment? A.NMPSIA does NOT offer an open enrollment for medical coverage. NMPSIA does offer an open enrollment for dental and vision coverage every year on January 1st.
Q. If I select a medical plan, will I have the opportunity to switch medical plans at a later date? A. Yes, your employer establishes a switch period with NMPSIA. Your employer will notify you of its switch enrollment period and provide you with instructions. (This switch enrolment period will also allow you the opportunity to switch your option under the NMPSIA Medical and Dental Plan, if you are enrolled in a Medical or Dental Plan at the time of switch enrolment.)
Q. If I enroll in the NMPSIA Vision Plan, may I drop this Plan at any time? A. No. As a safeguard to protect the utilization of the Vision Plan, NMPSIA has a 2-year enrollment requirement under this plan. You and each member of your family have to fulfill the 2-year enrollment requirement before you can drop vision coverage. If you are enrolled in a Section 125 Plan, other rules may apply. Check with your employer's Benefits Specialist for clarification.
Q. How will I know that my application for NMPSIA benefits has been processed and that my enrollment has been accepted? A. Upon receipt of your enrollment application, NMPSIA's Eligibility Administrator will mail you a Confirmation Notice or a Notice of Incomplete Enrollment. Review these notices carefully and immediately provide your employer's Benefits Specialist with any documentation requested to finalize your enrollment. Do this to avoid a delay or denial of coverage for your eligible dependents. You may contact your employer's Benefits Specialist for assistance or for clarification.
Q. I am a new hire and am applying for family coverage (employee + spouse + natural child + natural child), but I have not been able to locate my marriage certificate and birth certificate for one of my children. Will you still cover my wife and both children? A. We will initially cover you and the one child for whom you have provided a birth certificate. We will cover your spouse and your other child effective on the first day of the month following the date you provide this missing documentation to your employer's Benefits Specialist. (We will not cover these dependents retroactive to your initial effective date. You will be granted 61 days from your effective date of coverage to provide these missing documents. If you do not meet this deadline, your dependents will be considered late entrants.
Q. Both my husband and I are employed with NMPSIA school districts. He carries family dental and vision coverage with his employing school district. Can I enroll in family dental and vision coverage with my employing school district to double cover my eligible dependents for dental and vision coverage? A. No, NMPSIA Rules do not permit double coverage within the NMPSIA Group Plan for medical, dental, vision, and Additional life. You can have double coverage outside of the NMPSIA Group Plan.
FREQUENTLY ASKED QUESTIONS ABOUT HEALTHY VISTAS The health management program offered by NMPSIA if you are enrolled in the medical plans.
What is a Healthy Vistas Health Coach? A Health Coach is a specially trained professional such as a nurse, dietitian, or respiratory therapist who is prepared to talk with you on a variety of health issues.
How can a Healthy Vistas Health Coach help me? Your Health Coach can provide you with information and support to help you manage on-going health conditions such as diabetes, asthma, heart disease and depression. He or she can also help you with everyday health concerns you and your family may have. Your Health Coach will work with you to strengthen your relationship with your doctor.
When can I call a Healthy Vistas Health Coach? You may call and speak to a Health Coach anytime, day or night, 365 days a year!
What resources are available online? Healthy Vistas offers you free access to an entire library of WebMD resources. Online tools include your Health Quotient, a sympton checker, a blood pressure tracker, and access to WebMD Conditions Centers. Condition Centers provide you with tools and information on allergies, stress, cholesterol, depression and many more health topics.
What is a Health Quotient HRA? The HRA is a survey that asks about your health history and health habits. It takes about 15 minutes to complete. The Health Quotient uses your answers to develop a personalized plan to help improve your health. Just for completing the survey you will receive a $20 gift card!
Where can I go online to find these resources? Log in to your Personal Health Manager at www.webmdhealth.com/nmpsia to take your Health Quotient and to find all of these other great online tools and resources.
How much does it cost to use these services? All of the Healhty Vistas resources and services are offered to you at no charge. They are designed to keep you involved with your health.
FREQUENTLY ASKED QUESTIONS DENTAL PLAN INFORMATION FOR UNITED CONCORDIA
Q. How do I find out if my dentist is contracted with United Concordia? A. You can access provider network directory information by calling the toll-free Customer Service line at 1-888-898-0370 or by visiting United Concordia's web site at www.unitedconcordia.com.
Q. What does maximum allowable charge mean? A. The maximum allowable charge is the discounted amount that network dentists agree to charge for a covered service. United Concordia network dentists accept this amount as payment-in-full, collect only the applicable coinsurance from the member and cannot bill members for any amount over the maximum allowable charge.
Q. Do I have to complete claim forms for each dental visit? A. If you receive care from a United Concordia network dentist, you do not have to complete claim forms, as your dentist will take care of all the paperwork. However, if you receive care from an out-of-network dentist, you may have to complete and submit your own claims. You can obtain a claim form by calling Customer Service, contacting your Benefit's Office or downloading the form from the Member Services section of United Concordia's web site at www.unitedconcordia.com.
Q. Will United Concordia cover the replacement of teeth missing prior to effective date of coverage? A. No, United Concordia will not cover the replacement of teeth missing prior to your effective date of coverage under the New Mexico Public Schools Insurance Authority program.
Q. How will orthodontic benefits be paid if I am currently undergoing orthodontic treatment? A. An orthodontic treatment plan must be submitted by the treating provider in order to determine the remaining benefit for which you may be entitled.
Q. How can I know what my out-of-pocket costs will be for a procedure? A. For services other than routine diagnostic and preventative, most dentists will give you a pre-treatment estimate at the time they schedule your next appointment. This will give you an estimate of what the dentist expects to receive from your insurance per procedure. If you do not receive one, ask the dental office to provide a list of procedures to be performed and his fee. You can call Customer Service or go to My Dental Benefits on www.unitedconcordia.com to determine your plan allowance for these procedures. For more exact cost information, your dentist can file a request for predetermination of benefits.
Q. Does United Concordia require predetermination of benefits? A. No. However, you should consider asking your dentist to request a predetermination of benefits before you begin treatment for complex procedures, such as crowns, bridges, dentures or non-acute periodontal surgery. If you utilize an out-of-network dentist, you should consider a predetermination of benefits before beginning any treatment. That way, you'll know whether the service is covered and exactly what your financial responsibility will be.
Q. What is an Alternate Benefit Provision? A. An Alternate Benefit Provision is a limitation on all covered benefits. Frequently, several alternate methods exist to treat a dental condition. United Concordia will make payment based upon the allowance for the less expensive procedure provided that the less expensive procedure meets accepted standards of dental treatment. For example, a dentist may recommend putting a composite tooth-colored filling on one of your back posterior teeth. The plan will pay for an amalgam, silver filling only. If you elect to have the composite filling, you will be responsible for the difference between the allowance for an amalgam filling and the cost of the composite filling.
Q. Can I receive care from a dentist that is not contracted with United Concordia? A. Yes, you can receive care from any licensed dentist. If you choose to see an out-of-network dentist, you will be responsible for higher coinsurance amounts, subject to lower plan maximums, and billed for any charges over and above United Concordia's allowed amount for covered services. Contracted network dentists will accept United Concordia's maximum allowable charge as payment-in-full for covered services, which means you are responsible only for the applicable deductible and coinsurance amount.
Vision Benefits The vision benefit plan is administered by Davis Vision. This summary contains highlights only and is subject to change. The specific terms of coverage, exclusions and limitations are contained in Davis Vision's certificate. If there is any discrepancy between this document and the certificate, the terms of the certificate will govern.
What are the plan benefits? Every twelve (12) months you and your eligible dependents are entitled to: A routine eye examination, including dilation as professionally indicated; and spectacle lenses or contact lenses. Every twenty-four (24) months you and your eligible dependents are entitled to: A new frame.
Who are the network providers? They are licensed providers who are extensively reviewed and credentialed to ensure that stringent standards for quality service are maintained. Please call 1-800-999-5431 to access the Interactive Voice Response (IVR) Unit, or visit our website at www.davisvision.com, which will supply you with the names and addresses of the network providers near you.
How do I receive services from a provider in the network? Call the network provider of your choice and schedule an appointment. Identify yourself as a member or dependent of the New Mexico Public Schools Insurance Authority. Provide the office with the member's Social Security number and the year of birth of any covered children needing services.
What types of eyewear may I select? Any frame from the special Premier selection (with equivalent retail values up to $175.00), displayed on the Tower Collection in most network providers' offices. A $40.00 wholesale credit will be applied toward the purchase of a frame from the provider's private selection or a frame at a retail location. When receiving services from a provider who does not have the Tower Collection, such as a retail chain, the $40.00 wholesale credit will be applied to your purchase. Any spectacle lens type; many are included with your basic materials copayment. Contact lenses, in lieu of spectacle lenses; standard, soft, daily-wear, disposable or planned replacement types are available for most prescriptions. A $110.00 credit will be applied toward other types of contact lenses (i.e., toric or gas permeable from the providers private selection or retail location), fitting fees and recommended follow-up care. In some states, due to state mandate, the $110 credit can be applied to the contact lenses only. Members would then be responsible for the cost of fitting and follow-up fees. Medically necessary contact lenses will be covered in full (prior approval is required). Please note: Contact lenses can be worn by most people, but not by all. Once the contact lens option is selected and the lenses are fitted, they may not be exchanged for eyeglasses.
What are my costs for services? A $10.00 copayment is required toward your eye examination. A $15.00 basic copayment is required toward a plan frame and/or many spectacle lenses. No copayment will be required toward standard, soft, daily-wear, disposable, or planned replacement contact lenses, in lieu of eyeglasses. New and existing contact lens wearers will receive 2 standard, soft, daily-wear lenses, 2 boxes of planned replacement lenses or four boxes of disposable lenses.
What lenses/coatings are included? Plastic or glass single vision, bifocal or trifocal lenses, in any prescription range. Glass grey #3 prescription lenses. Oversize lenses. Post-cataract (lenticular) lenses. Fashion, sun or gradient tinted plastic lenses. Polycarbonate lenses (for dependent children and monocular patients).
Are there any optional lens types or coatings available? Yes, you can pay the low, discounted fixed fees indicated, (in addition to your basic materials copayment) and receive these exciting optional items. UV (ultraviolet) protective coating $12.00. Plastic Photosensitive (sun sensitive) lenses $65.00. Scratch-Resistant coating $20.00. High-Index (thinner and lighter) lenses $55.00. Photogrey Extra (sun-sensitive) glass lenses $20.00. Polarized lenses $75.00. Blended Invisible bifocals $20.00. Standard progressive add on multifocal brands** $50.00. Polycarbonate lenses $30.00. Premium progressive add on multifocal brands** $90.00. Standard Anti-Reflective coating $35.00. Intermediate Vision lenses $30.00. Premium Anti-Reflective coating $48.00. ** Progressive addition multifocals can be worn by most people, but not by all. Conventional bifocals will be supplied for anyone who is unable to adapt progressive addition lenses; however, the copayment will not be refunded.
When will I receive my eyeglasses? Your eyeglasses will be sent to your provider from the laboratory generally within two to five business days. Additional delivery time may be required when out-of-stock frames, glare resistant treatment, specialized prescriptions or non-Tower Collection frames are selected.
Are Laser Vision Correction Services available? Davis Vision is pleased to provide you and your eligible family members with the opportunity to receive Laser Vision Correction Services through a network of experienced, credentialed surgeons at a discount. For more information, please visit our website at www.davisvision.com and enter client code #7587 or call 1-800-584-2866.
Are Low Vision Services available? You and your covered dependents are entitled to a comprehensive low vision evaluation once every five years and low vision aids up to the plan maximum. Up to four follow-up care visits will be covered during the five year period. Prior approval is required for low vision services. Please contact Davis Vision for more information.
What about out-of-network provider benefits? You may receive services from an out-of-network provider, although you will receive the greatest value and maximize your benefit dollars if you select a provider who participates in the network. If you choose an out-of-network provider, you must: . Pay the provider directly for all charges; and . Submit a claim for reimbursement to: Davis Vision, P.O. Box 1525, Latham, NY 12110 Services will be reimbursed up to the following schedule of maximums: Eye examination $35.00. Lenticular lenses (per pair) $80.00. Single Vision Lenses (per pair) $25.00. A Frame $35.00. Bifocal Lenses (per pair) $40.00. Contact Lenses: Cosmetic $110.00. Trifocal Lenses (per pair) $55.00. Medically necessary $210.00. (prior approval required) To request claim forms, please call 1-800-999-5431 or visit our website at www.davisvision.com.
May I use the benefit at different times? To maintain continuity of care, we recommend that all available services be obtained at one time from either a network or an out-of-network provider.
Are there any exclusions? The following items are not covered by this vision program: . Medical treatment of eye disease or injury . Vision therapy . Special lens designs or coatings, other than those previously described . Replacement of lost eyewear . Non-prescription (plano) lenses . Services not performed by licensed personnel . Contact lenses and eyeglasses in the same benefit cycle . Two pairs of eyeglasses in lieu of a bifocal
Need more information? Please feel free to visit our website at www.davisvision.com or call Davis Vision at 1-800-999-5431 to: . Locate a network provider in your area . Verify eligibility for yourself or a family member . Request an out-of-network provider reimbursement claim form . Speak with a Member Service Representative . Ask any questions about your vision benefits
Member Service Representatives are available Monday through Friday, 6:00 AM to 9:00 PM, MST, Saturday, 7:00 AM to 2:00 PM, MST, and Sunday, 10:00 AM to 2:00 PM, MST.D.D. (Telephone Devise for the Deaf) services area available by calling 1-800-523-2847.  
Frequently Asked Questions: Long Term Disability The Long Term Disability coverage is provided by The Standard Insurance Company. Please refer to the certificate for ALL plan details, including any exclusions, limitations and restrictions which may apply. For The Standard LTD
What will my benefits be? Your monthly LTD benefits will be a percentage of your insured pre-disability earnings, up to the maximum of $5,000, less deductible sources of income and disability work earnings.
What are deductible sources of income? Deductible income includes but is not limited to benefits from statutory plans, Social Security amounts you, your spouse, or your children under age 18 receive or are eligible to receive because of your disability or your retirement; worker's compensation, and sick pay. (See your certificate for full details.)
When am I considered disabled? You are considered disabled if, as a result of physical disease, injury, pregnancy, or mental disorder, you are unable to perform with reasonable continuity the material duties of your own occupation, and you suffer a loss of at least 20% in your indexed pre-disability earnings when working in your own occupation. After the first 24 months for which LTD benefits are paid, you are considered disabled if, as a result of physical disease, injury, pregnancy, or mental disorder, you are unable to perform with reasonable continuity the material duties of any occupation.
What if I'm disabled and I return to work part-time? Will my benefits continue? Yes. The return to work incentive provision allows you to remain eligible for benefits while you are working part-time and are still disabled. Your monthly benefits may be reduced by a portion of your disability work earnings.
Will The Standard assist me with rehabilitation? While you are disabled, you may qualify to participate in a written plan, program or course of vocational training or education that is intended to prepare you to return to work. An approved rehabilitation plan may include payment by The Standard of some or all the expenses you incur in connection with the plan, including training and education expenses, family care expenses, job-related expenses, and job search expenses.
Does the plan limit payment for any disabilities? Yes. Disabilities due to mental disorders have a limited benefit period. Examples of mental disorders include, but are not restricted to, schizophrenia, depression, manic-depressive illness, bipolar affective disorder, substance abuse, and/or anxiety disorders. Disabilities due to mental disorders and certian other conditions have a combined limited benefit period. Examples of other limited conditions include, but are not restricted to, chronic fatigue conditions, allergy or sensitivity to chemicals or the environment, chronic pain conditions, and/or carpal tunnel syndrome.
Are any disabilities excluded from coverage? Yes. You are not covered for a disability caused or contributed to by war or any act of war, an intentionally self-inflicted injury, active participation in a riot, or committing or attempting to commit an assault or felony. You are not covered for a disability caused or contributed to by the loss of your professional license, occupational license or certification. Also, during the first 12 months of coverage, no LTD benefits will be paid for a disability caused or contributed to by a pre-existing condition or medical or surgical treatment of a pre-existing condition as defined by The Standard.
Do I have to pay premiums if I am disabled? No. While you are collecting disability benefits for more than 30 days, you do not have to pay premiums.