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Member NYSUT, AFT, NEA, ALF-CIO

Smithtown Teachers' Association

 President:  Rich Forzano   |   1^st Vice President:  Jane Cassidy   |    2^nd Vice President:   Laura Spencer
Secretary:  Joanne McEnroy     |     Treasurer:  Patty Stoddard
 

Healthcare FAQs

• Q.   I currently have individual coverage under the Suffolk School Employees Health Plan  (SSEHP) administered by United Healthcare.  I recently went to Massachusetts to marry  my same-sex partner.  Am I eligible for family coverage under SSEHP? 
  A.   Yes.  New York State recognizes marriages that are legally performed in other states or  countries.  Therefore, you and your spouse are eligible for the family plan in SSEHP 
   

  Q. My doctor has recommended that I get orthotics for my feet.  I do not need surgery, but I  am wondering if orthotics are covered under SSEHP? 
  A. The trustees recently voted to cover orthotics even if surgery  is unnecessary.  Effective January 1, 2009 orthotics will be covered up to $500 every  three years.  In addition, children who are 12 and under are covered for up to $250  annually.
   

  Q.   What is the maximum lifetime benefit of Suffolk School Employees Health Plan? 
  A.   The maximum benefit is $1,000,000 lifetime and $1,000,000 annually per covered  person.  Every year, the $1,000,000 “resets” and the person starts with a new $1 million.   If in any given year a person exceeds the $1 million, the excess costs are counted towards  the $1 million lifetime maximum.  See below for a few examples. 
  -      In one particular year, a person incurred medical costs of $800,000.  This $800,000 is counted towards the annual maximum of $1 million.  Since the annual costs did not exceed $1 million, the person’s lifetime $1 million maximum is unaffected.  The following year, this person still has the $1 million lifetime maximum and a new $1 million for the year.
  -      In one particular year, a person incurred medical costs of $1,400,000.  The first $1 million is counted towards the annual maximum of $1 million.  The $400,000 over the $1 million is counted towards the lifetime maximum of $1 million.  The following year, this person will have a new $1 million for the year and only $600,000 left in the lifetime maximum.

Q.   My daughter is graduating from college.  For how long can she receive health insurance  from SSEHP? 
A.   Your unmarried dependent children who are age 19 or older but under age 25 are eligible for  health benefits under SSEHP if they receive more than half of their support from you, and are  full-time students at an accredited secondary or preparatory school, college or other educational  institution and are otherwise not eligible for employer group coverage. They continue to be  eligible for coverage through the month in which they complete course requirements for  graduation. 
 

Q. If my doctor prescribes a Tier 3 medication and a generic form is not available, do I still have to  pay the $30 copay? 
A. Yes. 
 

Q. I liked going to Quest Diagnostics for my lab work.  I understand that the in-network labs  are now Labcorp, Enzo, Sunrise and Bioreference, but I prefer Quest.  Can I still go  there? 
A. Yes, but it will be covered as an out-of-network benefit which means the Plan will pay  80% of the reasonable and customary charges and you are responsible for the rest of the  bill. 
 

Q.   If I get admitted to a hospital, is there a co-pay? 
A.   Yes.  There is a $100 co-pay for an inpatient hospital visit whether it’s an in-network or  an out-of-network hospital. 
 

Q. Is there a co-pay if I go to the emergency room? 
A. Yes.  There is a $25 co-pay for emergency room visits in our plan. 
 

Q. I know there is a $25 co-pay for an emergency room visit.  If I get admitted to the  hospital during the same visit, do I have to pay the $25 plus the $100 inpatient hospital  co-pay?
A. No.  If you are admitted to a hospital through the emergency room, you will only have  the $100 co-pay. 
 

Q. I take a Tier 3 maintenance drug and pay $30 each month when I fill the prescription.   There are no Tier 1 or 2 alternatives available.  Is there a cheaper way for me to order this  drug? 
A. Yes.  SSEHP has a mail away program for these types of prescriptions.  You will pay the  same co-pay you currently pay in the pharmacy; however, you will receive a 90 day  supply in the mail.  This will cut your cost by 1/3.  The form can be downloaded by clicking here.  Be sure to have your doctor write a new prescription for a 90  day supply with 3 refills (if applicable).  There is normally a 7-10 day turnaround time  for the initial order.  Refills arrive faster. 
 

Q.   I am pregnant and was wondering if there is a special voluntary program for pregnant  women in our plan. 
A.   Yes.  UnitedHealthcare offers the Healthy Pregnancy Program to pregnant women.  This  voluntary program costs the patient nothing at all.  The program offers support and  resources via a 24-hour toll-free number to access experienced nurses.  You also receive  a free Healthy Baby Bag containing helpful items for the care of your baby.  You can  enroll by calling 1-800-411-7984. 

 

Q. What are our infertility benefits in the Suffolk School Employees Health Plan? 
A. If you go to an in-network provider then you must pay the $18 copay and out-of-network  providers are covered at the rate of 80% of reasonable and customary charges.  There is a  maximum lifetime benefit of $25,000, combined in and out-of-network.  This benefit includes the coverage of in-vitro fertilization and artificial insemination.  Any drug costs associated with the process do not count towards the $25,000 lifetime maximum. 
 

Q.   Is there a copy of our health plan book on the internet? 
A.   Yes.  You can view and download a copy by clicking here.  You can also login to  www.myuhc.com to see an overview of your benefits. 
 

Q. What is the outpatient mental health provision in our Plan? 
A. There is a network benefit as well as an out-of-network benefit.  If a member chooses to see an in-network provider for mental health services, the member will pay the $18 copay.  An out-of-network provider will be covered at the rate of 80% of the reasonable  and customary charges.  The patient is responsible for the balance of the bill.  Any  combination of network and out-of-network benefits for outpatient mental health  services is limited to 36 visits per calendar year.
 

Q. Is acupuncture covered under SSEHP? 
A. Yes, only if it is administered by an MD.  For an in-network provider, the member is  responsible for the $18 copay.  An out-of-network provider will be covered at the rate of  80% of the reasonable and customary charges.  The patient is responsible for the  balance of the bill.  Again, acupuncture is only covered if it is administered by an MD. 
 

Q.   Do I have to pay a co-pay at the doctor’s office for my children’s well visits? 
A.   If you take your child to an in-network provider, then there is no co-pay for routine well child care visits through age 19.  This includes office visits, routine physical examination, laboratory blood tests, x-rays, hearing tests, vision tests and immunizations through age 19. 
 

Q. Does SSEHP have a chiropractic benefit? 
A. Yes.  If you go to an in-network provider, then there will be an $18 co-pay for the visit.   If you choose to see an out-of-network provider, then the Plan will pay 80% of the  reasonable and customary charges, after your deductible is met, and you are responsible  for the rest of the bill.  Benefits include diagnosis and related services and are limited to  one visit and treatment per day. (Review after 15^th visit)