A: With the "Preferred Provider Organization" (PPO) plan, participating providers are covered at 90% (after deductible) for the majority of covered services, and non-participating providers are covered at 70% (after deductible) plus potential "balance billing".

Q: Who is eligible?

A: All full-time employees who regularly work 30 hours or more per week are eligible for coverage.  Once eligible, you may also enroll your spouse and/or your dependent children.  Eligible dependent children are:  Any never married natural child, stepchild, legally adopted child, child placed with you for adoption or child for whom you or your spouse has court appointed guardianship or custody.  The child must be: 1)  Under age 23; 2) primarily dependent on you for financial support; and 3) legally claimed as an exemption on your latest federal income tax return if one was filed. 

Q: When does coverage take effect?

A: Coverage is effective the 1^st of the month following 90 days of employment.

Q: Are pre-existing conditions covered?

A: As long as you had 12 months of continuous, creditable medical insurance prior to enrolling in the Mountain Adventures/BCI plan, your pre-existing conditions will be covered according to plan provisions.  Continuous coverage means that there was not a lapse of more than 63 days, not counting your 90 day probationary period, immediately prior to your enrollment in the Mountain Adventures/BCI plan.

Q: How do you receive care?

A: You will maximize your benefits by utilizing "Participating" or "Preferred" Blue Cross of Idaho physicians, hospitals and other allied providers.  Simply present your I.D. card, and these "Participating" and/or "Preferred" providers will submit the claims for you.  A listing of "Participating" and "Preferred" providers is available online.

Q: What happens if a provider will not accept my card?

A: This usually means that the provider is non-participating with Blue Cross of Idaho, and therefore your benefits may be less.  It also means that you will need to obtain from the provider and submit an itemized bill yourself to Blue Cross of Idaho with an accompanying claim form.

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Q: Is pre-approval required under our plan?

A: Pre-Admission Review is required for all inpatient hospital admissions except for covered services subject to emergency admission review.

In emergency situations, you or your representative must notify Blue Cross of Idaho within 24 hours after your admission.  If your admission falls on a weekend or legal holiday, you must notify BCI by the end of the next working day.  If it is medically impossible for you to do so, once you are medically able, you must notify BCI.

The Pre-Admission Review phone number is (800) 627-1187.

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Q: Do I need a "referral" to see a specialist?

A: No.  Neither the Traditional nor the Preferred Provider plan require referrals from a Primary Care Physician to see a specialist.

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Q: Are naturopaths or acupuncturists covered?

A:  Acupuncturists and Naturopaths are not covered providers under the medical insurance plan, however, Blue Cross of Idaho does have a special discount program for these types of services, called "Natural Blue".  Click on the Natural Blue link for more information.  

A:  Preventive care is covered subject to a $20 co-pay per insured, per visit, but only if a Preferred Provider is utilized.  Preventive care is not covered out-of-network.  See Benefit Booklet for more details.

A:  For Participating Pharmacies, Generic Drugs are subject to a $5 co-pay, and Brand Name Drugs are subject to a $12 co-pay.

Each prescription shall not exceed a thirty-four (34) day supply, unless purchased through an approved, participating mail order pharmacy, where the prescription shall not exceed a 90 day supply.  Please see Benefit Booklet for more details. 

A: Please refer to the Blue Cross of Idaho Benefit Booklet under the "Exclusions" section.

A: If the answer is not clear after reviewing your benefit booklet, please contact Blue Cross of Idaho's Customer Service Department to confirm coverage. 

A: If you have a claim question, please contact Blue Cross of Idaho's customer service department via e-mail, or call them at (800) 627-1187.  If you do not get an adequate answer, please contact either Jane Doe in your HR department, or Your Broker at ABC Insurance (our agent).

A: Claim forms will be required when you must submit the bills to BCI yourself, usually with non-participating providers or non-participating pharmacies. 

A: A treatment plan should be submitted by your dentist to BCI prior to your treatment for the following procedures:  Crowns, Full or Partial Dentures, Inlays, Periodontal Surgery (including curettage), Bridgework, Surgical Removal of Impacted Teeth, Laminate Veneers and Bonding Procedures.

If a claim for completed treatment is submitted that includes covered services for which benefits have not been pre-determined, the claim will be reviewed in the same manner as if it were being submitted for pre-determination.  BCI will consider whether alternate procedures would have produced a professionally satisfactory result.  If you and your dentist have chosen a more expensive method of treatment than is determined professionally satisfactory by BCI, BCI will pay benefits for the less expensive treatment.  The excess amount will be your responsibility.

A:  No.  Please see Benefit Booklet for a listing of covered dental services, exclusions and limitations.

A: Your Group Term Life Insurance benefit, paid for by Mountain Adventures, is two times your annual earnings, rounded to the next higher $1,000, if not already a multiple of $1,000.  The maximum benefit is $400,000, or with satisfactory evidence of insurability $500,000.  

A: Yes, you are covered for an additional two times your annual salary if your death is the result of an accident, and also covered for varying amounts for certain other losses and/or dismemberments.  Please refer to your Benefit Booklet for more details on this coverage.

A: No.  Since you pay the full cost of the LTD premiums, your benefit is not taxable as income.

A: Yes.  Your LTD plan provides 24 hour coverage.  However, income received from other sources such as Worker's Compensation for being injured on the job, will be integrated with your long term disability benefits.

A: If you elected to waive LTD coverage when initially eligible for it, and you wish to enroll at a future date, evidence of insurability will be required. 

A: Yes, if you have a disability arise during the first 12 months you are insured due to a pre-existing condition, then that disability will not be covered by the plan.  A condition is considered pre-existing if during the 90 days immediately prior to your enrollment on the plan, you consulted a physician, received medical care or services, or took prescription drugs or medications.

A: The Employee Assistance Program (EAP) is a confidential counseling and referral service that can help you and your family successfully deal with life's challenges.

A: Call the EAP whenever you need help sorting through what's happening in your life. Call when you need a new perspective on things. Call when you need help identifying options and making an informed choice about what to do next. The Employee Assistance Program is always there for you---even if it's in the middle of the night or on a holiday.

A: All charges for the Employee Assistance Program have been pre-paid by your employer. While there are no co-payments or fees for the EAP, your employee assistance professional may refer you to additional resources for help. Their charges, if any, would be your responsibility, so you may want to check your company benefits.

A: When you call your EAP, an employee assistance professional will ask you to describe what's happening that's causing your concern. When the cause of the problem has been determined, you and your employee assistance professional will develop a mutually agreeable plan to deal with the situation. This may consist of scheduling a face-to-face assessment or, in the case of an emergency, offering you assistance right over the phone.

A:  Idaho and Nevada residence call 1-800-424-5930.  Alaska residence call 1-800-478-5930.

FLEXIBLE SPENDING PLAN

Q: How much can I defer into the plan?

A: You can defer up to $5,000 into your Medical Reimbursement Account and $5000 into your Dependent Care Account $5,000.00.  

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Q: When does the plan year begin?

A: The Plan Year is the period beginning on January 1 and ending on the last day of December.

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Q: How long do I have to file claims?

A: All reimbursement accounts will be closed ninety (90) days after the end of each Plan Year (or the date you cease to be eligible). To be processed, vouchers for expenses incurred during the Plan Year must be received before the accounts are closed. Vouchers for claims in excess of your annual elected benefit cannot be carried over to subsequent Plan Years.

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