- Are AmeriCorps*VISTA members and AmeriCorps*NCCC members covered by health insurance?
No, AmeriCorps members do not have insurance. The health benefits plan for AmeriCorps is a self-funded plan. That means it is paid for by the Corporation for National & Community Service (CNCS), with funds appropriated by the Congress; your tax dollars. The approved benefits are paid directly by CNCS. There is no insurance company involved.
- Will this health benefits plan cover medical conditions that have already been diagnosed and treated?
No. The health care plan does not cover pre-existing conditions.
- What is a pre-existing condition?
A pre-existing condition is any physical or mental condition or illness for which medical treatment was given, or a diagnosis was made, on or before the effective date of coverage. If you have received medical attention for any physical or mental illness or condition before entering AmeriCorps, treatment of that illness or condition is your responsibility; treatment for that illness or condition is not a covered benefit.
- Is there coverage for dental care?
Coverage is limited and only for emergencies. Routine dental visits are not covered.
- How are my medical bills paid?
If you receive service for an approved benefit your claim will go to Seven Corners, Inc., the contractor administering the health benefits plan. Seven Corners pays those claims that are for approved benefits. When a claim is submitted by your doctor, Seven Corners pays the claim according to the guidelines established by CNCS in the Member Health Care Guide. Seven Corners is responsible for:
- determination if the claim is for an approved benefit;
- payment of the claim or denial of the claim;
- appeals and;
- customer service.
Seven Corners is under contract to CNCS to provide these services. It is not an insurance company. It ensures that your claim is valid, covered by the benefits plan and paid according to the rules as described in the Member Health Care Guide.
- I currently have health insurance, should I keep it?
It depends. Only you can decide. It is always preferable to have more coverage than needed as opposed to not enough. You should examine the coverage you currently have and compare it to the limited coverage you will get in AmeriCorps. Ask for a copy of the Member Health Care Guide or go online at www.americorps.sevencorners.com.
Questions commonly asked during service with AmeriCorps.
- Who do I call if I have questions about the health benefits plan?
Call Seven Corners, the health benefits administrator toll free at 866-699-4186.
- What happens if I go to the doctor and the claim is denied by Seven Corners?
Examine the reason given for the denial carefully. Read the Explanation of Benefits (EOB) that accompanied the denial. Ask the doctor or her office manager why the claim was denied. Read the Member Health Care Guide. If you believe it should be paid according to the Member Health Care Guide you can appeal the decision.
- What happens if the health benefits plan won't pay after my appeal?
You are responsible for paying the claim.
- I went to the doctor and now I'm getting a bill, what should I do?
You should call the provider for further information.
The most common reasons for this are:
- No claim was ever sent. Verify that the provider sent a claim to Seven Corners;
- The doctor or hospital is billing you instead of sending the bill to Seven Corners. Verify that a claim has been submitted to Seven Corners;
- Our claims administrator, Seven Corners, has asked the provider for more information concerning your claim before it can be paid. Verify that the provider has sent the information requested. Ask the provider to read you the Explanation of Benefits they received from Seven Corners;
- You were treated for a pre-existing condition. Since the health benefits plan specifically excludes pre-existing conditions, you are responsible for paying the entire claim;
- You received care that is not a covered benefit. Check the Member Health Care Guide.
- How do I get a new health care card?
Call Seven Corners, the health benefits administrator toll at free 866-699-4186.
- What is a Preferred Provider Network (PPO) and why is it important to me?
A PPO is a network of health care providers that have agreed to participate in our plan. These providers bill the plan directly, will not require payment in advance from you (except for the $5 co-pay) and have agreed to a pre-determined fee for all services.
Using the PPO can save you money. If you do not go to a provider in the PPO network you will be responsible for paying the difference between what the provider charges and what is a "usual and customary" fee for that service. Using the PPO can save you money.
- What if there is no PPO in my area?
If there is no PPO in your area, then you may go to any provider and you will not be penalized. You should make very sure that there are no providers in you area; if there are you will be responsible for any difference between the charges and what we pay.
You may visit the Seven Corners website at http://americorps.sevencorners.com/ or you can call Seven Corners toll free at 866-699-4186 to verify if there is a PPO in your area.
- Who is responsible for my health care and for the bills I have?
You are responsible for your health care and for making sure that the treatment you are seeking is a covered benefit, and that all the information required to pay your bills has been forwarded to the proper place. You should not assume that information will automatically be sent to Seven Corners by your provider and you should not assume that your bill will be paid automatically. If you are having problems getting a bill paid, it is your responsibility to work with the provider and Seven Corners to make sure that all required information has been sent to Seven Corners.
- Am I covered by worker's compensation?
The Federal Employee's Compensation Act covers you for those injuries and illnesses incurred while you are on duty; you are eligible to file a claim AFTER you have terminated your service with AmeriCorps. Until you have terminated your service these medical costs are covered by the AmeriCorps Health Benefits Plan.
Yes, you are covered by worker's compensation. If you are injured on the job call your state office for information on how to file a claim.
- Am I eligible for COBRA?
No, you are not eligible for COBRA. COBRA applies to group health care plans in the private sector. The AmeriCorps health benefits plan is not a group health care plan as defined in the COBRA law and AmeriCorps is not a private sector organization.
- Is there a way I can get health insurance after service?
Yes. You can call Celtic Insurance Company at 1-800-365-2365 for information on how to get individual health insurance. You MUST call within 31 days of your termination date.
- What is pre-certification?
The term "pre-certification" means:
The pre-certification process also includes three other important factors:
- You have been certified as active in the AmeriCorps program and verified as receiving the AmeriCorps Health Benefit, and
- This medical condition requires admittance to the hospital instead of outpatient care.
What it does NOT mean.
- It documents that the hospital is in the provider network and, if it is not, provides notice to the hospital that you will be responsible for those charges that exceed the cost paid by the plan (you may have to pay);
- It provides warning that the AmeriCorps Health Benefits plan provides limited benefits and does not cover pre-existing conditions; and
- It verifies that "pre-certification" is not a guarantee of payment.
"Pre-certification" does not mean the procedure for which you are admitted is guaranteed to be covered by the AmeriCorps Health Benefits plan. Pre-certification does not change the terms of the plan. The plan will NOT cover pre-existing conditions and will NOT cover benefits excluded in the plan.
Does the pre-certification process make sense?
Yes. You are responsible for knowing what the plan covers and what it does not cover. When you or hospital calls for "pre-certification," the Customer Service Representatives at Seven Corners explain to you and to the hospital that "pre-certification" does not guarantee payment. Seven Corners' Customer Service Representatives carefully explain that the plan provides limited benefits and does not cover pre-existing conditions.
Following this verbal explanation a fax containing this information is sent to the hospital.
Seven Corners CANNOT promise that payment for a claim will be approved in advance because Seven Corners CANNOT know what the physician or hospital will include on the claim. To approve or deny a claim Seven Corners can only use the information that is on the claim or in the medical records. If the information on the claim is not sufficient to make a decision Seven Corners will then request all medical records relevant to the claim. It is not possible to know in advance what will be on the claim or in the medical records.