- Grandfathered Status
- Designation of Primary Care Provider
- Newborns' and Mothers' Health Protection Act
- Mastectomy Benefits
- Loss of Medicaid or CHIP Eligibility
1. Grandfathered Status
Duke University believes that the Duke Health Plans are a “grandfathered health plan” under the Patient Protection and Affordable Care Act (the Affordable Care Act). As permitted by the Affordable Care Act, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Being a grandfathered health plan means that your plan may not include certain consumer protections of the Affordable Care Act that apply to other plans, for example, the requirement for the provision of preventive health services without any cost sharing. However, grandfathered health plans must comply with certain other consumer protections in the Affordable Care Act, for example, the elimination of lifetime limits on benefits.
Questions regarding which protections apply and which protections do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the plan administrator at Duke Human Resources at 919-684-5600. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272 or www.dol.gov/ebsa/ healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans.
2. Designation of Primary Care Provider
You have the right to designate any primary care provider who participates in our network and who is available to accept you or your family members. For information on how to select a primary care provider, and for a list of the participating primary care providers, contact Duke Human Resources at 919- 684-5600. For children, you may designate a pediatrician as the primary care provider.
You do not need prior authorization from Duke Health Plans or from any other person (including a primary care provider) in order to obtain access to obstetrical or gynecological care from a health care professional in our network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining prior authorization for certain services, following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact Duke Human Resources at 919-684-5600.
3. Newborns’ and Mothers’ Health Protection Act
Under federal law, group health plans and health insurance issuers offering group health insurance coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the attending provider (e.g., your doctor, nurse midwife or physician assistant), after consultation with the mother, discharges the mother or newborn earlier.
Also, under federal law, group health plans and health insurance issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48- hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay.
In addition, a plan or issuer may not, under federal law, require that a doctor or other health care provider obtain certification for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain certification.
4. Mastectomy Benefits
In accordance with the Women’s Health and Cancer Rights Act of 1998, the Duke Health Plans provide for the following services related to mastectomy surgery:
- Reconstruction of the breast on which the mastectomy has been performed
- Surgery and reconstruction of the nondiseased breast to produce a symmetrical appearance without regard to the lapse of time between the mastectomy and the reconstructive surgery
- Prostheses and physical complications of all stages of the mastectomy, including lymphedemas.
The benefits described above are subject to the same co-payment or coinsurance and limitations as applied to other medical and surgical benefits provided by Duke Health Plans.
5. Medicaid and the Children’s Health Insurance Program (CHIP)
If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer sponsored plan.
Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer’s health plan is required to permit you and your dependents to enroll in the plan – as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance.
If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of April 16, 2010. You should contact your State for further information on eligibility.
ALABAMA – Medicaid
Phone: 1-800-362-1504
ALASKA – Medicaid
Phone (Outside of Anchorage): 1-888-318-8890
Phone (Anchorage): 907-269-6529
ARIZONA – CHIP
Phone: 1-877-764-5437
ARKANSAS – CHIP
Phone: 1-888-474-8275
CALIFORNIA – Medicaid
Phone: 1-866-298-8443
COLORADO – Medicaid and CHIP
Medicaid Phone: 1-800-866-3513
CHIP
CHIP Phone: 303-866-3243
FLORIDA – Medicaid
Phone: 1-866-762-2237
GEORGIA – Medicaid
Click on Programs, then Medicaid
Phone: 1-800-869-1150
IDAHO – Medicaid and CHIP
Medicaid
Medicaid Phone: 1-800-926-2588
CHIP
CHIP Phone: 1-800-926-2588
INDIANA – Medicaid
Phone: 1-877-438-4479
IOWA – Medicaid
Phone: 1-888-346-9562
KANSAS – Medicaid
Phone: 800-766-9012
KENTUCKY – Medicaid
Phone: 1-800-635-2570
LOUISIANA – Medicaid
Phone: 1-888-342-6207
MAINE – Medicaid
Phone: 1-800-321-5557
MASSACHUSETTS – Medicaid and CHIP
Medicaid & CHIP Phone: 1-800-462-1120
MINNESOTA – Medicaid
Click on Health Care, then Medical Assistance
Phone: 800-657-3739
MISSOURI – Medicaid
Phone: 573-751-6944
MONTANA – Medicaid
Phone: 1-800-694-3084
NEBRASKA – Medicaid
Phone: 1-877-255-3092
NEVADA – Medicaid and CHIP
Medicaid
Phone: 1-800-992-0900;
CHIP
Phone: 1-877-543-7669
NEW HAMPSHIRE – Medicaid
Phone: 1-800-852-3345 x 5254
NEW JERSEY – Medicaid and CHIP
Medicaid
Medicaid Phone: 1-800-356-1561;
CHIP
CHIP Phone: 1-800-701-0710
NEW MEXICO – Medicaid and CHIP
Medicaid
Medicaid Phone: 1-888-997-2583;
CHIP
Click on Insure New Mexico
CHIP Phone: 1-888-997-2583
NEW YORK – Medicaid
Phone: 1-800-541-2831
NORTH CAROLINA – Medicaid
Phone: 919-855-4100
NORTH DAKOTA – Medicaid
Phone: 1-800-755-2604
OKLAHOMA – Medicaid
Phone: 1-888-365-3742
OREGON – Medicaid and CHIP
Phone: 1-877-314-5678
PENNSYLVANIA – Medicaid
Phone: 1-800-644-7730
RHODE ISLAND – Medicaid
Phone: 401-462-5300
SOUTH CAROLINA – Medicaid
Phone: 1-888-549-0820
TEXAS – Medicaid
Phone: 1-800-440-0493
UTAH – Medicaid
Phone: 1-866-435-7414
VERMONT– Medicaid
Phone: 1-800-250-8427
VIRGINIA – Medicaid and CHIP
Medicaid
Phone: 1-800-432-5924
CHIP
CHIP Phone: 1-866-873-2647
WASHINGTON – Medicaid
Phone: 1-877-543-7669
WEST VIRGINIA – Medicaid
Phone: 304-342-1604
WISCONSIN – Medicaid
Phone: 1-800-362-3002
WYOMING – Medicaid
Phone: 307-777-7531
To see if any more States have added a premium assistance program since April 16, 2010, or for more information on special enrollment rights, you can contact either the U.S. Department of Labor Employee Benefits Security Administration at www.dol.gov/ebsa (1-866-444-3272) or the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services at www.cms.hhs.gov (1-877-267-2323, ext. 61565).