Frequently Asked Questions: Health

HSA

• ACS/Mellon HSA FAQ

Eligibility

• Who is eligible for health insurance coverage?
• How long can my child be insured as my dependent?

Monthly Contributions

• Cost

Enrollment

• Domestic partner
• Changes
• Dependents

Life Events

• Leave of absence
• Retire
• Resignation/end of appointment

General Information

• Contact Information
• Coverage options
• What is Plan A?
• What is an HMO?
• HMO vs. PPO?
• What are the differences between the health plans? ( PDF)
• How can I find out if my physician is in the provider network?
• Can I receive care from any physician?
• Can the PPO pre-existing condition provision be waived if I had health insurance from a foreign country?
• Co-insurance
• Walgreens Health Initiatives (WHI).
• Primary care physician
• Pre-existing conditions
• What do I do if I get sick while away from Chicago?

Claims

• What do I do if I get a bill from my physician?

Eligibility

Who is eligible for health insurance coverage?

Faculty and Staff Northwestern University regular status staff scheduled to work at least 17.5 hours per week are eligible. Faculty appointed on a full-time or part-time (50% - half-time or greater) basis for the entire academic year or appointed on a full-time (100%) basis for one-half the academic year are eligible. One-half the academic year is defined as either two consecutive quarters or one semester.

Visiting Scholars Visiting Scholars who are appointed on at least a half-time basis.

NRSA Funded Post Doctoral Fellows

Spouse An employee's spouse must be legally married to and have his or her principal residence with the employee to be eligible.

Children Unmarried dependent children may be covered through age 22 regardless if they are not a full-time student. Coverage terminates at the end of the month in which the 23rd birthday occurs. Dependent children include natural, step, and legally adopted children.

Domestic Partner An employee may enroll his or her same-sex domestic partner and any eligible dependent children of the domestic partner.

Surviving Spouse & Children The surviving spouse and dependent children (children through age 22) are eligible to continue health, dental & vision coverage through Northwestern University in the Retiree Plan.

Go to Retiree Eligibility ( PDF)

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How long can my child be insured as my dependent?

Unmarried dependent children may remain insured as dependents until their 23th birthday. Children who cease to be eligible as dependents may continue coverage on their own by paying the full cost for up to 36 months under a federal law referred to as COBRA.

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Monthly Contribution Rates

How much does health insurance coverage cost?

Contributions payments for health insurance coverage are made by payroll deduction on a pre-tax basis. Individuals on an unpaid leave of absence, separated or retired pay monthly contributions by check.

Access monthly contributions

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Enrollment

Can I enroll my domestic partner?

Yes. The University's health care plan will cover the same-gender domestic partner of an employee. To enroll, an employee must complete a Declaration of Same-Gender Domestic Partner Relationship and enroll the partner using the online eBenefis enrollment process. The difference between the University and employee premium for single and family coverage is considered taxable income to the employee.

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How and when do I change my health plan?

Each year during Open Enrollment, you may elect to enroll in the health care plan, change from one health care plan or another, or add coverage for a spouse or dependent child. Changes become effective January 1.

At any other time, a change from single to family coverage may be made within 31 days from the date of a qualified change in family or employment status. Examples of a qualified change in family status include: a birth, adoption, change in marital status, death of spouse or dependent, or change in spouse employment status.

After initial employment or benefits eligibility, an individual may change from single to family coverage within 31 days from a qualified change in family or employment status. Also, after initial employment or benefits eligibility, an individual may enroll in a health plan or switch from one health plan to another only during Open Enrollment. The change becomes effective January 1st of the next year.

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When can my dependents be added to my health plan?

An employee may enroll his or her spouse and eligible dependent children within 31 days from the date of employment.

Employees may also add coverage for a spouse or children within 31 calendar days from the date of a qualified change in family status (marriage, birth, adoption, etc). Otherwise, coverage for dependents may be added during Open Enrollment with coverage effective January 1st of the next year.

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Life Events

What happens to my insurance in the event of a medical leave of absence?

Health plan coverage may be continued during a disability-related unpaid leave of absence. The University's continues to make its contribution.

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What happens to my insurance during a period of personal leave without pay?

Members on personal leave without pay may continue coverage for up to 12 months subject to the member's payment of 100% of the premium which includes the University's contribution.

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What happens to my insurance when I retire?

When you retire, you may continue health insurance coverage provided you meet the eligibility requirements including that you are at least age 55 and have at least 10 years of continuous full-time University service at the time of retirement.

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What happens to my insurance when I resign or my appointment ends?

Persons leaving employment at the University are entitled to continue health coverage for up to 18 months under the Consolidated Omnibus Budget Reconciliation Act (COBRA). Cost of coverage is borne fully by the employee. There is no University contribution toward COBRA coverage. Notice of the COBRA Continuation option is sent to employees by the Benefits Division soon after their resignation or appointment ending date.

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General Information

What are my coverage options?

You may select either single or family coverage.

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What is Plan A?

Plan A was one of the five health insurance plans offered to eligible Northwestern University faculty and staff. It was a self-insured PPO health care plan covering comprehensive care by any physician or hospital selected by a covered member. Benefits are higher if health care services are received from an in-network provider. Effective January 1, 2007, Plan A is being referred to as the Premier PPO plan. Features of the plan will the same as Plan A.

Self-Insured vs. Fully-insured

A self-insured plan refers to health plans which are funded by employee and employer contributions and deposited to a trust. Claims and other plan expenses are paid from the trust. Any remaining monies at the end of the plan year are retained as plan assets.

Under fully-insured plans, Contributions are deposited to an insurance company. Any remaining monies at the end of the plan year become assets of the insurance company and not the plan.

The Premier PPO plan is administered by Blue Cross and Blue Shield of Illinois for hospital and physician services and by Walgreens Health Initiatives, a prescription benefit management company.

Benefits are higher when provided from a network of hospitals and physicians.

The plan does not cover pre-existing conditions or preventive services (except mammograms, pap smears and well care for dependent children under age 16). It requires the timely filing of claim forms, otherwise benefits will be denied.

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What is an HMO?

A Health Maintenance Organization (HMO) provides medical care from a network of physician and hospital providers, generally emphasizes preventive services, covers eligible hospital and physician services at 100%, and does not require the completion of claim forms. An HMO only covers health care services which are authorized in advance by an individual's primary care physician.

For further information about HMOs

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What are the differences between an HMO and a PPO?

A Health Maintenance Organization (HMO) only provides care from a network of physicians and hospitals which is authorized in advance by an individual's primary care physician. A Participating Provider Organization (PPO) is a network of physician and hospital providers offered by Blue Cross to PPO members. These providers have agreed to accept the Blue Cross payment schedule as payment in full for covered services. PPO benefits are higher when provided by a PPO provider than by a non-PPO provider..

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How can I find out if my physician in the provider network?

You should contact the health plan directly. Each plan offers a 1-800 telephone number.

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Can I receive care from any physician?

Yes. While an individual may receive care from any physician, an HMO will only authorize care when care is either provided directly by the individual's primary care physician or authorized in advance by the individual's primary care physician.

Plan A members may receive care from any physician. Benefits are higher when provided by a network provider.

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Can the PPO pre-exising condition provision be waived if I previously had health insurance coverage from a foreign country?

Yes. The proof of foreign coverage can be a copy of any document showing residency in the foreign country or showing evidence that eligibility standards have been met (i.e., a benefit booklet, an explanation of coverage, an ID card, etc., issued by the foreign health plan that identifies the subscriber and/or dependent). The period of time with the foreign coverage will also have to be given in the documentation or separately by letter.

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What is co-insurance?

The term 'co-insurance' refers to the sharing of PPO costs between covered individuals and the Plan. For example, when care is provided by network providers, The Premier PPO plan pays 90% of eligible charges and members pay 10%. When care is provided by a non-network provider, The Premier PPO plan pays 70% of eligible charges and members pay 30%. Participant co-insurance is summarized in the following table.

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What is Walgreens Health Initiatives?

Walgreens Health Initiatives (WHI) is a national prescription drug benefit manager. WHI provides prescription drug services from a national network of over 55,000 pharmacies including most major retail pharmacy chains such as Walgreens, Osco, K-mart, and many local neighborhood independent pharmacies. WHI provides such services to Premier PPO, Select PPO and HMO Illinois members.

Established in 1991, WHI, part of the 100-year-old Walgreen Co., promotes employee health with comprehensive, individually designed pharmacy benefit management (PBM) programs. Serving more than 400 clients representing 2.6 million covered lives, WHI offers a nationwide retail pharmacy network, mail service pharmacy, specialty pharmacy, and, in select geographic areas, home care services and products

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How do I change my primary care physician?

To change your primary care physician (PCP) within the same medical group, all you need to do is to contact the medical group.

To change your PCP to a different medical group, contact member services of your HMO.

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Are pre-existing conditions covered when enrolling in a PPO plan?

Benefits (other than for maternity services and the prescription drug program) are subject to a pre-existing conditions waiting period of 365 days. The PPO plans do not cover pre-existing conditions for one year from the date of the effective date of coverage. If an employee had health coverage prior to the effective date of Northwestern University PPO coverage without a break in coverage of more than 63 days, the pre-existing conditions waiting period is waived. New employees must submit to Blue Cross a Certificate of Creditable coverage from the previous health plan. Contact Blue Cross for further information.

The pre-existing conditions provision does not apply to individuals who enroll in a PPO plan during Open Enrollment.

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What do I do if I get sick while away from Chicago?

The PPO plans provide coverage of emergency and non emergency care outside of the Chicago area, including foreign countries. Benefits are greater if care is provided by an affiliated Blue Cross provider through the (Blue Card Program).

If a participating Blue Cross & Blue Shield provider is utilized, payment will not be required up front. However, if a non-participating provider is utilized, payment will be required at the time of service, and member will need to submit a claim for reimbursement.

The plan pays for ambulance or equivalent medical transportation to the nearest medical facility qualified for treatment in the case of a true accident or medical emergency. Transportation to another city or country would not be covered for a non-emergency situation.

Transporting remains back to the U.S. is not a covered benefit.

HMO plans provide coverage for out-of-area life-threatening or severe emergencies.

HMO may require notification to the plan of emergency within a designated period of time. Unless otherwise authorized, follow-up care must be received from or coordinated by the member's selected Primary Care Physician.

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Claims

What do I do if I get a bill from my physician?

If you are a member of a PPO plan, you should obtain a claim form from Blue Cross or from the Benefits Division, complete the form and submit the completed form directly to Blue Cross. If you are a member of an HMO, you should contact the HMO directly.

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