GTFF - Health Care

Forms
Brief Summary of Benefits
Frequently Asked Questions

pacific source forms
Pacific Source Health Care Handbook: pacific_source_handbook_2004.pdf Pacific Source Health Care Enrollment Form: stop by the office to enroll in the health care. Pacific Source Medical/Dental/Vision Claim Form: pacific_source_med_claim_form.pdf Pacific Source Perscription Claim Form: pacific_source_rx_claim_form.pdf Affidavit of Domestic Partnership: affidavit_of_domestic_partnership.pdf If you have questions, you can contact Lisa Hamilton, our health care administrator, at (541) 344-0832 or via email at . The ASH Affinity Program. Through this affinity program, members can save up to 25 percent on complementary healthcare services, including chiropractic, acupuncture, dietetic counseling, and massage therapy. Best of all, the program is provided at no cost! Download.

pacific source forms

Pacific Source Health Care Handbook: pacific_source_handbook_2004.pdf
Pacific Source Health Care Enrollment Form: stop by the office to enroll in the health care.
Pacific Source Medical/Dental/Vision Claim Form: pacific_source_med_claim_form.pdf
Pacific Source Perscription Claim Form: pacific_source_rx_claim_form.pdf
Affidavit of Domestic Partnership: affidavit_of_domestic_partnership.pdf

If you have questions, you can contact Lisa Hamilton, our health care administrator, at (541) 344-0832 or via email at .

The ASH Affinity Program. Through this affinity program, members can save up to 25 percent on complementary healthcare services, including chiropractic, acupuncture, dietetic counseling, and massage therapy. Best of all, the program is provided at no cost! Download.

brief summary of benefits
Medical Benefits Once you have met your $100 deductible, if you are using a preferred provider, your medical services will be covered at 90%. Non preferred providers are covered at 70%, after your deductible is met. Dental Benefits There is no preferred list of dentists. You will be covered at 100% of usual and customary charges for one cleaning, one exam and one set of x-rays, once every six months, regardless of the dentist you choose. For minor dental services (such as fillings) you will pay a $25 deductible and then 20% of the charges, PacificSource covers 80%. There is no major dental coverage on this plan. Prescription Benefits Prescriptions are covered at 70%. At major chain pharmacies, all you need to do is show your insurance card and pay your 30% co-pay. At the Student Health Center, you will need to show your insurance card, pay 100% of the cost, fill out a prescription reimbursement form, send it to PacificSource, and wait for 70% back. Prescriptions (including birth control) are only covered in 30 day supplies. Vision Benefits You have $200 to spend on vision services. This includes your eye exam, frames, lenses, contacts, etc. Any amount over $200 is your responsibility. Preferred providers are covered at 100%, up to the $200 limit. Non preferred providers are covered at 40%, up to the $200 limit.

brief summary of benefits

Medical Benefits

Once you have met your $100 deductible, if you are using a preferred provider, your medical services will be covered at 90%. Non preferred providers are covered at 70%, after your deductible is met.
Dental Benefits

There is no preferred list of dentists. You will be covered at 100% of usual and customary charges for one cleaning, one exam and one set of x-rays, once every six months, regardless of the dentist you choose. For minor dental services (such as fillings) you will pay a $25 deductible and then 20% of the charges, PacificSource covers 80%. There is no major dental coverage on this plan.
Prescription Benefits

Prescriptions are covered at 70%. At major chain pharmacies, all you need to do is show your insurance card and pay your 30% co-pay. At the Student Health Center, you will need to show your insurance card, pay 100% of the cost, fill out a prescription reimbursement form, send it to PacificSource, and wait for 70% back. Prescriptions (including birth control) are only covered in 30 day supplies.
Vision Benefits

You have $200 to spend on vision services. This includes your eye exam, frames, lenses, contacts, etc. Any amount over $200 is your responsibility. Preferred providers are covered at 100%, up to the $200 limit. Non preferred providers are covered at 40%, up to the $200 limit.

frequently asked questions
Please visit the PacificSource website for further questions http://www.pacificsource.com. More questions? Ask Chris, . When does coverage start? Can I add dependents? Does that include Domestic Partners? How much does insurance cost? How much is my deductible? What is payroll deduction? How do I sign up for summer coverage? Am I eligible? How do I find a Preferred Provider? Can I use the Health Center? Do I have to pay up front? How do I file a claim? What is my group number? What is Pacific Source’s Address? I have still have questions about our health care plan. Who do I contact? When does coverage start? For Fall term, September 16. You may not receive your forms, insurance card, etc. until after this date, but not to worry! Your insurance is retroactive back to September 16 even if you get your information afterwards. Coverage always starts the 16th of the first month of each quarter (if you enroll partway through the year instead of at the beginning). Insurance runs from: September 16 - December 15 for fall term December 16 - March 15 for winter term March 16 - June 15 for spring term June 16 - September 15 for summer term Can I add dependents? Does that include Domestic Partners? Yes, and Yes. If you choose not to insure your dependents when you initially enroll yourself, you will have the option to add them in September and in March, during one of the Open Enrollment periods. You can also add a new dependent within 30 days of them becoming your dependent (birth, adoption, marriage, domestic partnership). All dependent additions are effective on the 16th of the month following their eligibility. If you are adding a Domestic Partner, you will need to complete an Affidavit of Domestic Partnership (available at the GTFF Office, and electronically here), and have it notarized. The UO Bookstore has a notary service, and will do it for you for free. How much does insurance cost? During the academic year (Fall, Winter, and Spring terms) the university pays 100% for your personal insurance, you pay nothing. If you choose to enroll dependents on the plan, you have to pay the following amounts per term: just spouse or domestic partner $234.70 just child(ren) $165.03 family (spouse or domestic partner AND a child or children) $400.90. The following rates apply for summer term coverage: it is $221.80 for a GTF to stay on the plan for the summer term. Dependent summer rates are listed below. Summer term coverage runs from June 16 through September 15. For a GTF and just spouse or domestic partner $457.68 GTF and just child(ren) $388.00 GTF and family (spouse or domestic partner AND a child or children) $623.88. How much is my deductible? The deductible is $100 per person and $300 per family before plan benefits begin. Please refer to the PacificSource handbook (available above for a complete description of coverage levels and provided services. What is payroll deduction? A small amount of money is taken out of your paycheck each month and goes into your summer insurance account. By the time summer rolls around you will have automatically paid for your summer insurance in small, painless chunks throughout the year rather than one really large chunk in June. We strongly recommend this option! You can also fill out a payroll deduction form to cover dependent premiums during the academic year, instead of paying by check at the beginning of each term. Payroll Deduction Forms are available in the GTFF office. Did we mention that we strongly recommend this option? How do I sign up for summer coverage? Am I eligible? If you are insured on the GTFF Health Plan during the spring term, then you are eligible for the summer coverage. You will automatically be sent a bill in early June, to your home address (make sure you keep us updated of changes). If you want the coverage, just pay that bill and you wll be covered through September 15th. Otherwise, ignore it, and your coverage will end June 15th. New Summer GTFs are also eligible for the summer coverage, and will be asked to pay for it as they enroll. If you are a spring GTF, and fail to pay your summer bill, you will not be re-eligible based on a summer GTF appointment. How do I find a Preferred Provider? The best place to look is on the PacificSource website (http://www.pacificsource.com/) where you will find a link to the 'Provider Directory'. These are all of the medical and vision preferred doctors on our plan. All of the doctors are at the student health center are also considered preferred and covered at the full 90%. Can I use the Health Center? Yes. This is a very good option; it is on campus and very good for nearly all your medical and dental needs. However, if you use the Student Health Center, you will be responsible for filing your own claims. The Health Center will automatically bill your student account, but not PacificSource. If you use the Student Health Center, you will need to: request a claim form from them (it can take up to a week to get back, but happens in a few minutes in person) fill out the top portion of it (with information form your insurance card) send it in to PacificSource (the address is on your card). Do I have to pay up front? In most cases, no. However, if you are using a non-preferred provider, or the pharmacy at the student health center, they might require some kind of payment. As long as you use preferred providers and major chain pharmacies, you should never have to pay up front. If you use the Student Health Center you can bill your student account. How do I file a claim? If you are using a preferred provider, they should take care of all the claims processing for you. Be sure you give them your insurance information when you get there. If you are using a non preferred provider, or your doctor didn’t bill the insurance company, for whatever reason, there are claim forms in the GTFF office (and available electronically above) that can be attached to doctor/dentist bills and then sent in to PacificSource. If you are using the Student Health Center, see #7. What is my group number? It’s 7896. Your ID number is the number shown on your insurance card, beginning with the letter R. What is Pacific Source’s Address? PacificSource P.O Box 7068 Eugene, OR 97401 (541) 686-1242 or (800) 624-6052 I have still have questions about our health care plan. Who do I contact? You can refer to the Pacific Source Handbook (available electronically above) to find most answers to your questions. If you still cannot find the desired information or would like to speak with someone in person you may contact Pacific Source directly at (541) 684-5582 or (888) 977-9299. You may also contact our benefits administrator at the GTFF office (541) 344-0832 or . General concerns about health care bargaining, member benefits, or other problems or input regarding Pacific Source or the status of our health care can be directed to VP Member Benefits at .

frequently asked questions

Please visit the PacificSource website for further questions http://www.pacificsource.com. More questions? Ask Chris, .

When does coverage start?
Can I add dependents? Does that include Domestic Partners?
How much does insurance cost?
How much is my deductible?
What is payroll deduction?
How do I sign up for summer coverage? Am I eligible?
How do I find a Preferred Provider?
Can I use the Health Center?
Do I have to pay up front?
How do I file a claim?
What is my group number?
What is Pacific Source’s Address?
I have still have questions about our health care plan. Who do I contact?

When does coverage start?

For Fall term, September 16. You may not receive your forms, insurance card, etc. until after this date, but not to worry! Your insurance is retroactive back to September 16 even if you get your information afterwards. Coverage always starts the 16th of the first month of each quarter (if you enroll partway through the year instead of at the beginning).

Insurance runs from:
- September 16 - December 15 for fall term
- December 16 - March 15 for winter term
- March 16 - June 15 for spring term
- June 16 - September 15 for summer term
Can I add dependents? Does that include Domestic Partners?

Yes, and Yes. If you choose not to insure your dependents when you initially enroll yourself, you will have the option to add them in September and in March, during one of the Open Enrollment periods. You can also add a new dependent within 30 days of them becoming your dependent (birth, adoption, marriage, domestic partnership). All dependent additions are effective on the 16th of the month following their eligibility. If you are adding a Domestic Partner, you will need to complete an Affidavit of Domestic Partnership (available at the GTFF Office, and electronically here), and have it notarized. The UO Bookstore has a notary service, and will do it for you for free.
How much does insurance cost?

During the academic year (Fall, Winter, and Spring terms) the university pays 100% for your personal insurance, you pay nothing. If you choose to enroll dependents on the plan, you have to pay the following amounts per term:
- just spouse or domestic partner $234.70
- just child(ren) $165.03
- family (spouse or domestic partner AND a child or children) $400.90.
The following rates apply for summer term coverage:
- it is $221.80 for a GTF to stay on the plan for the summer term. Dependent summer rates are listed below. Summer term coverage runs from June 16 through September 15.
- For a GTF and just spouse or domestic partner $457.68
- GTF and just child(ren) $388.00
- GTF and family (spouse or domestic partner AND a child or children) $623.88.
How much is my deductible?

The deductible is $100 per person and $300 per family before plan benefits begin. Please refer to the PacificSource handbook (available above for a complete description of coverage levels and provided services.
What is payroll deduction?

A small amount of money is taken out of your paycheck each month and goes into your summer insurance account. By the time summer rolls around you will have automatically paid for your summer insurance in small, painless chunks throughout the year rather than one really large chunk in June. We strongly recommend this option! You can also fill out a payroll deduction form to cover dependent premiums during the academic year, instead of paying by check at the beginning of each term. Payroll Deduction Forms are available in the GTFF office. Did we mention that we strongly recommend this option?
How do I sign up for summer coverage? Am I eligible?

If you are insured on the GTFF Health Plan during the spring term, then you are eligible for the summer coverage. You will automatically be sent a bill in early June, to your home address (make sure you keep us updated of changes). If you want the coverage, just pay that bill and you wll be covered through September 15th. Otherwise, ignore it, and your coverage will end June 15th. New Summer GTFs are also eligible for the summer coverage, and will be asked to pay for it as they enroll. If you are a spring GTF, and fail to pay your summer bill, you will not be re-eligible based on a summer GTF appointment.
How do I find a Preferred Provider?

The best place to look is on the PacificSource website (http://www.pacificsource.com/) where you will find a link to the 'Provider Directory'. These are all of the medical and vision preferred doctors on our plan. All of the doctors are at the student health center are also considered preferred and covered at the full 90%.
Can I use the Health Center?

Yes. This is a very good option; it is on campus and very good for nearly all your medical and dental needs. However, if you use the Student Health Center, you will be responsible for filing your own claims. The Health Center will automatically bill your student account, but not PacificSource.

If you use the Student Health Center, you will need to: request a claim form from them (it can take up to a week to get back, but happens in a few minutes in person) fill out the top portion of it (with information form your insurance card) send it in to PacificSource (the address is on your card).
Do I have to pay up front?

In most cases, no. However, if you are using a non-preferred provider, or the pharmacy at the student health center, they might require some kind of payment. As long as you use preferred providers and major chain pharmacies, you should never have to pay up front. If you use the Student Health Center you can bill your student account.
How do I file a claim?

If you are using a preferred provider, they should take care of all the claims processing for you. Be sure you give them your insurance information when you get there. If you are using a non preferred provider, or your doctor didn’t bill the insurance company, for whatever reason, there are claim forms in the GTFF office (and available electronically above) that can be attached to doctor/dentist bills and then sent in to PacificSource. If you are using the Student Health Center, see #7.
What is my group number?

It’s 7896. Your ID number is the number shown on your insurance card, beginning with the letter R.
What is Pacific Source’s Address?

PacificSource
P.O Box 7068
Eugene, OR 97401
(541) 686-1242 or (800) 624-6052
I have still have questions about our health care plan. Who do I contact?

You can refer to the Pacific Source Handbook (available electronically above) to find most answers to your questions. If you still cannot find the desired information or would like to speak with someone in person you may contact Pacific Source directly at (541) 684-5582 or (888) 977-9299. You may also contact our benefits administrator at the GTFF office (541) 344-0832 or . General concerns about health care bargaining, member benefits, or other problems or input regarding Pacific Source or the status of our health care can be directed to VP Member Benefits at .