Medical
Where can I find a list of available doctors/hospitals?
Go to “Find a Doctor” at www.Aetna.com. Select Choice POS II (Red, White, Green and Bridge Plan) or Aetna Select (Blue Plan).
For step-by-step instructions, click here.
What fertility benefits are being offered in the medical plans and are they available in all four plans?
Nemours Children’s provides comprehensive and inclusive fertility benefits and additional pregnancy and parenting support resources. The benefit design allows you and your doctor to pursue the most effective treatment and provides coverage for two smart cycles. These fertility benefits are available to associates enrolled in any one of the four medical plans (Red, White, Blue or Green).
What if my spouse’s employer offers benefits?
If you are currently enrolled in a Nemours plan but have the opportunity to enroll in your spouse’s plan (non-Nemours), you will want to consider our SAVI plan. Your premium for SAVI is $0, and it will pay 100% of the out-of-pocket costs incurred from your spouses’ medical plan up to the Affordable Care Act (ACA) maximums (2023 limits are $9,100/single and $18,200/family per year).
Note that SAVI is available if you are a new associate and enroll in alternative coverage (except for Medicaid, Medicare, TRICARE and HSA plans) or if you are a current associate enrolled in a Nemours benefit plan and enroll in alternative coverage with the exceptions previously noted. You and your spouse should weigh which plan works best for your circumstances.
What is the spousal surcharge for 2023?
The spousal surcharge for 2023 is $300 per month. This surcharge is applicable only when your spouse has access to medical coverage through his/her/their employer and you decide to cover him/her/them through a Nemours medical plan. If your spouse is not covered by Nemours, there is not a spousal surcharge. Note that the spousal surcharge will continue to be waived if you both work at Nemours. If your spouse has access to medical coverage from his/her/their employer, you can avoid the spousal surcharge and lower your out-of-pocket costs by enrolling in the SAVI Plan. Note that you are required to update the status of your spouse’s coverage availability during annual enrollment.
Which of the plans has the greatest tax advantage?
The Green Plan includes a health savings account (HSA). An HSA account offers a triple tax advantage to those who enroll in it. Associates can contribute tax free, earn tax-free interest on their investments and use the funds for eligible medical expenses tax free.
Prescription Drug
How do I participate in the mail order drug plan with Express Scripts?
Refer to information available on the Express Scripts website.
How can I find out if the brand name drug that I am taking has a chemical equivalent?
A listing of chemically equivalent drugs is difficult to maintain because as brand name drugs lose their patents, new chemically equivalent generic drugs are manufactured.
You must register on the Express Scripts website; after doing so, you’ll be able to research your options as well as obtain pricing information. At the top right of your prescription, it shows generic and brand name; you can compare each on the site.
How can I avoid paying the difference in cost between a brand name drug and a chemically equivalent generic drug?
You may ask your doctor to circle “Substitution Allowed” on the prescription that he/she/they writes for you. By law, your pharmacist may only substitute a chemically equivalent generic if your doctor has circled “Substitution Allowed” rather than “Dispense as Written.”
There are certain exclusions to this rule as mandated by state law.
The brand name drug I am taking has a chemically equivalent generic drug available. I’ve tried the generic, and I had a bad reaction to the drug. What can I do?
Your physician may file an appeal with Express Scripts. They may provide you with a prior authorization that will allow you to fill your prescription without having to pay the difference in cost.
I use mail order for my prescription drugs. Will the Generics Preferred Program apply to my mail order medications?
Yes, this program will apply to mail order.
How will I be notified by Express Scripts if the cost of my mail order medication will be increasing?
If Express Scripts does not have a credit card on file for you, they will notify you if your order exceeds $150. If Express Scripts has a credit card on file for you, they will notify you if your order exceeds $500.
What happens if my doctor’s request for a prior authorization is denied?
Our pharmacy benefit plan’s guidelines exclude certain drugs from coverage. To learn more about what drugs are excluded under our plan, look in your plan summary.
For a copy of the criteria our plan uses to decide which prior authorizations will be covered, call Express Scripts. An agent can send you a copy of the criteria. The number to call is on the back of your prescription card.
OR
If you want to file an appeal to have your prescription drug covered, our plan has an appeals process. Call Express Scripts at the number on the back of your prescription card to get the address to which you should send your appeal. You may also reach out to Health Advocate to help with appeals.
Voluntary Vision
Do I need an ID Card?
No, you do not need to present an ID card to prove coverage or confirm that you are eligible. Identify yourself as a VSP member to your eye care provider.
What will be covered through this benefit?
This vision benefit provides added discounts when services are sought through the preferred provider listing. See the summary of vision care benefits.
What providers are considered in-network?
For the most part, VSP only contracts with private ophthalmologists or optometrists. Most major eye care chains, such as Lenscrafters and Sears Vision are NOT covered as in-network providers by VSP because they do not meet VSP’s quality assurance standards.
However, many of these chains will provide discounts for their eyewear if you identify yourself as a VSP member.
Please note that changes in network status can occur at any time. Check with your provider prior to your next appointment.
My eye care provider is out-of-network. How do I get reimbursed for my expenses?
An out-of-network claim form is available from VSP. To access, click here.
Are my contact lenses “elective” or “necessary”?
If your contact lenses are considered medically necessary (in other words, you can’t wear glasses), they will be reimbursed at 100%.
If you have the option of wearing glasses or contacts, your contact lenses are considered “elective,” and your allowance will be determined by the plan you elect.
I need both glasses and contact lenses—what should I do?
Frames may only be reimbursed one year after filling a prescription for contact lenses. We therefore recommend that you fill your prescription for glasses and lenses FIRST, and then, in the following calendar year, fill a prescription for contact lenses.
Contact lenses/glasses lenses are considered interchangeable, so you may EITHER receive your allowance for lenses or for contacts in any given calendar year.
Are disposable contact lenses covered under this plan?
Yes. You may use your elective contact lens allowance toward disposable contact lenses. If your disposable lens charges are under the allowable amount for the calendar year, you may continue to be reimbursed for disposable lenses until you have reached the $120 or $150 allowance.
Thereafter, you may be eligible for discounts on your disposable lenses.
Are polycarbonate or bicarbonate lenses covered for adults?
Charges for polycarbonate or bicarbonate lenses are not covered under the normal lens co-pay. However, you may elect to pay the extra charge for poly- or bicarbonate lenses.
I understand that if I wear soft contact lenses, I may be eligible for additional discounts—how does this program work?
Ask your doctor if you might be eligible to participate.
Under the soft contact lens program, instead of having an allowance toward contacts AND the contact fitting exam, you will receive a 15% discount off the contact fitting exam, PLUS a $120 or $150 allowance toward contact lenses. This program will generally allow you to receive six months of soft contact lenses without cost.
Dental
What is a participating dentist and how do I locate one?
A general dentist or specialist who meets strict credentialing standards and accepts scheduled fees as payment-in-full for services rendered. To get a list of participating dentists, call 800.932.0783 to have a list faxed or mailed to you or go to the online provider search.
How does the Passive PPO Work?
With our plans, you receive a wide range of benefits whether or not you and/or each eligible dependent visit a participating dentist. But, when you visit a participating dentist (an “in-network dentist”), you have the opportunity to make the most of your benefit plan through access to lower out-of-pocket expenses. Out-of-network dental providers can balance bill.
Can I find out how much services will cost and what will be covered prior to treatment?
Delta Dental strongly recommends that you have a dentist submit a pre-treatment estimate for services in excess of $300. While you wait, your dentist can get a real-time pre-treatment estimate online or over the phone in minutes detailing what services the plan will cover and at what payment level. PPO plans pay for the least expensive clinically appropriate course of treatment. Therefore, licensed dental consultants review certain services such as crowns, bridges and periodontics for appropriateness and necessity.
Do I need an ID Card?
No, you do not need to present an ID card to prove coverage or confirm that you are eligible. However, Delta Dental does issue ID cards to help identify you as a member of the Nemours Delta Dental program, and claims filing information is provided in the online benefits Library.
How are composite fillings covered?
Composite (or tooth-colored) fillings on posterior teeth are considered an optional service. If you receive an optional service when the alternate benefit of amalgam (silver) fillings are available, Delta Dental will base the benefit on the lower cost of the amalgam filling. Members will be responsible for the difference in cost.
Term Life Insurance and Accidental Death & Dismemberment
Describe your Evidence of Insurability requirements. When would evidence be required (e.g., with change in election, when a salary increase causes an increase in benefit, after initial approval)? How often is evidence required?
Evidence is needed for anyone applying for amounts above the Guaranteed Issue limit, anyone applying after the eligible enrollment period or anyone wanting to increase coverage. This applies to both employee and spouse coverage. We also require Evidence of Insurability when the person does not elect coverage initially.
Disability
What is the most common cause of disability claims delays?
The most common reason that a Long-Term Disability claim is delayed is that the claim form is not complete. To most effectively ensure the processing of a claim, check to be sure that all questions on the form are answered, the policy number is on the form and that the employer portion is completed by the Nemours Benefits Team.
Flexible Spending Accounts
What records do I keep for tax purposes?
Keep receipts for at least a year; the IRS requires auditing of certain debit card transactions. See the FSA Debit Card section for more information.
Can I use the Health Care FSA to pay for my spouse’s deductibles and/or co-payments if they are not covered by my group medical plan?
Yes. However, health care premiums deducted from your spouse’s paycheck and premiums for individual insurance policies are not eligible.
To what age may I use the Dependent Care FSA for daycare expenses incurred for my child?
You may submit expenses incurred for your dependent child before his/her/their 13th birthday, or longer if disabled.
Are expenses for before/after school programs considered eligible expenses?
Yes, but you must separate the cost of such care from the cost of the school.
Are Over-the-Counter (OTC) Medications Covered?
OTC medications are covered only if you have a prescription from your provider. You may not use your debit card to purchase an OTC medication, but you may submit a claim for reimbursement. You must submit a copy of the script with the claim form in order for the expense to be reimbursed.
IMPORTANT NOTE FOR DIRECT DEPOSIT: Each individual bank has its own rules as to when it processes the direct deposit payments it receives. Associates should consult with their bank for details.
Termination of Employment
What happens to my benefits if I terminate employment with Nemours Children’s Health?
Your benefits options vary depending on what you had in force prior to your termination. Different benefits have different continuation options. For example, Medical, Dental, Vision and Health Care Flexible Spending Accounts may be continued for specified periods of time through COBRA. Term Life insurance may be ported or converted, and Long Term Care may be taken with you at exactly the same rates that you currently pay.
There are limits to the amount of time that you have to make elections to continue terminated coverage. You may find a detailed listing of benefits available upon termination (and information about those benefits) in the Termination of Benefits Summary.
How will my dependent child(ren)’s coverage be impacted by a status change or termination of employment?
Nemours Children’s Health provides coverage for your eligible dependent child(ren) until the end of the month during which they turn 26. You should be aware of how their benefits are impacted by certain circumstances such as turning 26. If you terminate employment with Nemours Children’s, your dependent children are eligible for COBRA. The COBRA options available to your dependents may vary depending on your status as an active employee (whether you are full-time or part-time), and your dependent’s age as of termination.