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SECTION 8: EMPLOYEE BENEFITS AND INSURANCE

Information on the following state sponsored plans is available through the Personnel Office:

  • Health
  • Dental/Dental Plus
  • Vision
  • Dependent Child Term Life Insurance
  • Dependent Spouse Term Life Insurance
  • Optional Term Life Insurance
  • Supplemental Long-Term Disability Insurance
  • Money Plus Premium
  • Dependent Care Spending Account
  • Medical Spending Accounts
  • Health Savings Accounts

Eligible Dependents An Eligible Spouse

  • Is a lawful spouse 

An Eligible Child   – Health, Dental, Dental Plus and Vision

  • Must be younger than age 26
  • Must be the subscriber’s natural child, adopted child (including child placed for legal adoption), stepchild, foster child, a child for whom the subscriber has legal custody or a child the subscriber is required to cover due to a court order.

-A foster child is a child placed by an authorized placement agency with the subscriber, who is a licensed foster parent.

-A child for whom the subscriber has legal custody is a child for whom the subscriber has guardianship responsibility, not merely financial responsibility, according to a court order or other legal document.

If you and your spouse are both eligible for coverage, only one of you can cover your children under any one plan. However, one parent can cover the children under health, and the other can cover the children under dental.

Eligible Child for Dependent Life Insurance
A dependent child, age 19-24, must be a full-time student, not in the military and not married to be covered under Dependent Life-Child Insurance.  Please note: If a child is found to be ineligible for Dependent Life-Child coverage, benefits will not be paid.

An Incapacitated Child
You can continue to cover your child who is age 26 or older if he/she is incapacitated and you are financially responsible for him. To cover your dependent child who is incapacitated, he/she must meet these requirements:

  • The child must have been continuously covered by health insurance from the time of incapacitation.
  • The child must be unmarried and must remain unmarried to continue eligibility.
  • The child must be incapable of self-sustaining employment because of mental illness, retardation or   physical disability and must remain principally dependent (more than 50 percent) on the covered employee, retiree, survivor or COBRA subscriber for support and maintenance. Incapacitation must be established no earlier than 90 days before the child’s 26th birthday (or before the child’s 19th birthday for him/her to be covered under Dependent Life-Child) but no later than 30 days after the date he/she is no longer eligible for coverage as a child.

Documentation Needed To Carry Dependents
You will need documentation when you add someone to coverage. Example: Spouse: Marriage License, Child(ren): Birth Certificate that lists the employee as parent.

To order a Marriage License/Birth Certificate from another state:  http://www.cdc.gov/nchs/w2w.htm

To order a Marriage License/Birth Certificate from SC:  www.scdhec.gov/administration/vr/index.htm.

(WE RECOMMEND THAT YOU GO IN PERSON TO THE SUMTER HEALTH DEPARTMENT TO GET A BIRTH CERTIFICATE PRINTED, PROVIDED THE BIRTH TOOK PLACE IN SC.)

Insurance
All full-time permanent employees must complete a Notice of Election Form.  Part-time permanent teachers working 15-30 hours per week qualify for state health & dental insurance – at a much higher rate than full time.

Important Insurance Rules:
31 Day Rule – Employees have 31 days from one of the following occurrences to meet with the District Benefits Coordinator and sign the form to add or drop coverage for Birth, Death, Marriage, Divorce, Adoption or Placement, Involuntary Loss of Coverage or Gain of Coverage.

Open Enrollment
For Health and Vision-Occurs every October. At this time employees can drop or add Health and/or Vision insurance on themselves or any eligible dependent.

Changes go into effect in January.

For Dental and Dental Plus– Occurs every odd year in October.  At this time employees can drop or add Dental and/or Dental Plus insurance on themselves or any eligible dependent

Changes go into effect in January.

MEDI-CALL
Getting prior authorization for your medical care 

Health care prior authorization with the State Health Plan, some covered services require prior authorization by a phone call to Medi-Call before you receive them. Your health care provider may make the call for you, but it is your responsibility to ensure the call is made. To preauthorize your medical treatment, call MediCall at 800.925.9724. 

Please note that in addition to regular health coverage, some behavioral health care services as well as radiology (imaging service) and prescription drug benefits also require prior authorization. See Page 51 for behavioral health, Page 52 for radiology and Page 84 for prescription drugs. 

Lab work prior authorization
Certain lab services require prior authorization and require that your provider request Avalon Healthcare Solutions (Avalon)19 review these services prior to performing the services. Requests may be submitted for prior authorization to Avalon by fax at 888.791.2181 or by phone at 844.227.5769), 8 a.m. to 8 p.m., Eastern Time. Once Avalon receives the request, it will be reviewed by Avalon’s clinical staff and they will notify your provider of the determination. An authorization for lab work does not guarantee payment. 

Penalties for not calling
If you do not prior authorize treatment when required, you will pay a $490 penalty for each hospital, rehabilitation, skilled nursing facility or behavioral health admission. The penalty amount does not apply to your deductible or coinsurance maximum.

How to prior authorize your treatment
Medi-Call numbers are: 

  • 803.699.3337 or 800.925.9724. • 803.264.0183 (fax). 

You can reach Medi-Call by phone from 8:30 a.m. to 5 p.m., Monday through Friday, except holidays. You may also fax information to Medi-Call 24 hours a day; Medi-Call will respond within two business days. If you send a fax to Medi-Call, provide, at a minimum, the following information so the review can begin: 

  • Subscriber’s name;
  • Patient’s name; 
  • Subscriber’s BIN; 
  • Information about the service requested; and 
  • A telephone number at which you can be reached during business hours. Medi-Call promotes high-quality, cost-effective care for you and your covered family members through reviews that assess, plan, implement, coordinate, monitor and evaluate health care options and services required to meet an individual’s needs. You will need to contact Medi-Call at least 48 hours or two working days, whichever is longer, before receiving any of these non-emergent medical services at any hospital in the United States or Canada:
  • Any type of inpatient care in a hospital, including admission to a hospital to have a baby20; • A preauthorized outpatient service that results in a hospital admission – you must call again for the hospital admission; • Outpatient surgery for a septoplasty (surgery on the septum of the nose); 
  • Outpatient or inpatient surgery for a hysterectomy; 
  • Sclerotherapy (vein surgery) performed in an inpatient, outpatient or office setting; 
  • A new course of chemotherapy or radiation therapy (one-time notification per course); 
  • A radiology (imaging) procedure ; 
  • Pregnancy – you are encouraged to notify Medi-Call within the first three months of your pregnancy ; 
  • An emergency admission during pregnancy; 
  • Birth of a child (if you plan to file a claim for any birth-related expenses); 
  • Baby has complications at birth; 
  • Are going to be, or have been, admitted to a long-term acute care facility, skilled nursing facility or need home health care, hospice care or an alternative treatment plan; 
  • Need durable medical equipment; 
  • Undergoing in vitro fertilization, GIFT, ZIFT or any other infertility procedure – this includes you and your covered spouse; 
  • Need to be evaluated for a transplant – includes you or your covered spouse or family member; and
  • Need inpatient rehabilitative services and related outpatient physical, speech or occupational therapy

When coverage ends:  Insurance coverage will end the last day of the month in which you terminate employment with the district.  In certain situations, you may be eligible for a limited extension of benefits under the federal legislation known as COBRA.

Employees may make an appointment with their designated Benefits Administrator for more information about employee benefits and insurance. Employees may also download the current Benefits Guide located on PEBA’s website at: www.peba.sc.gov

The most current information regarding the state’s health plan can be found at:  www.peba.sc.gov