COE Insurance

IAFF Center of Excellence

Verification of Insurance

The Center of Excellence’s internal insurance verification team will call a member’s insurance provider to verify benefits offered apply for services at the Center of Excellence.

The following information must be provided to verify insurance benefits:

  • Name of insurance provider
  • Insurance provider’s customer service phone number
  • Name of member as written on  insurance card
  • Member date of birth
  • Member ID number
  • In some cases, providers will require a member’s Social Security number to verify benefits

The IAFF admissions team will then relay the benefit information back to the client, including deductibles, co-insurance percentages and out-of-pocket annual maximums that the insurance provider has disclosed would apply to a member’s treatment at the Center.

With the member’s permission, the Center of Excellence can contact local, state/provincial or district leaders to assist with any financial barriers.

What to do if insurance is denied for a member in urgent need of treatment:    

  • Pursue a single-case agreement. A single case agreement is a contract between an insurance company and an out-of-network provider for a specific patient, so that the patient can see that provider using their in-network benefits. A single case agreement addresses the unique needs of the patient and the cost benefits to the insurance company rather than an in-network provider. Single case agreements can be granted for patients who need clinical treatment that is not available with any of the in-network providers or for treatment at a facility that is not available locally. Patients must make the case for a single case agreement with the out-of-network provider before beginning treatment. Affiliate leaders have also successfully lobbied for approved single case agreements for their members – both with insurers and benefits managers.
  • If a member needs emergency services, find treatment at another behavioral health facility until access restrictions to the Center of Excellence are resolved.
  • Call IAFF Director of Behavioral Health Services Will Newton at (202) 824-9303 for immediate assistance.
  • Establish a benevolent fund for members who experience behavioral health issues and are seeking treatment at the Center of Excellence (see sample benevolent fund policy).
In-Network Providers

America’s Choice Provider Network (ACPN)
Aetna
CareFirst BCBS*
Cigna
CompAlliance
Corvel Workercomp
Healthcare Solutions Group
Humana
First Choice
First Health
Gig Harbor Firefighter Union Trust
Medical Benefit
Medical Mutual
Mines and Associates
Moda Health
Northwest Firefighter Trust
United Healthcare (UHC)
UPMC Health Plan
Vancouver Firefighters Union Trust

NOTE: HMO plans may have geographical limitations for services and health insurance providers who are not in network may not provide members out-of-network benefits – and subsequently, no coverage for services. PPO plans provide the greatest ability to access the Center of Excellence with less likelihood of insurance obstacles.

*Accessing the Center of Excellence Through Blue Cross Blue Shield
The BlueCard Program provides in-network access for many, but not all Blue Cross Blue Shield affiliated-plans. Most PPO plans will have in-network access and policies that are part of the BlueCard or BlueOptions program. Receiving health care services out of state is optional and may not be offered by your specific plan. If you are an IAFF member with insurance through Blue Cross Blue Shield, you must first verify that your benefits cover treatment at the Center of Excellence.

Levels of Care

  • Detox
  • Intensive Inpatient
  • Residential
  • Partial Hospitalization Program
  • Intensive Outpatient Program
  • Outpatient Program
Know your Health Insurance

Using insurance to cover the cost of treatment can make a significant impact on the overall cost and the type of care members are eligible to receive.

Benefits will fall under two categories:

  1. Health Maintenance Organization (HMO) – a medical insurance group that provides health care services through a network of providers that have set rates for their plan members and that acts as a liaison with health care providers (hospitals, doctors, etc.). An HMO typically only covers providers that are in their network.
  2. Preferred Provider Organization (PPO) – a subscription based managed care organization comprised of medical doctors, hospitals and other health care providers. A PPO health plan offers increased flexibility when selecting a treatment provider.
  3. Exclusive Provider Organization (EPO) – a type of health plan that offers a local network of doctors and hospitals to choose from. An EPO is usually more pocket-friendly than a PPO plan, but if you choose to receive care outside of your plan’s network, it is typically not covered (except in an emergency). If you’re looking for lower monthly premiums and are willing to pay a higher deductible when you need health care, you may want to consider an EPO plan.
  4. Point of Service (POS) – a managed care plan that is a hybrid of HMO and PPO plans. Similar to an HMO, participants designate an in-network physician as their primary care provider. But like a PPO, patients can outside of the provider network for health care services. When patients venture out of network, they pay most of the cost, unless the primary care provider has made a referral to the out-of-network provider.

The Center of Excellence is now in network with most insurance plans.

  • Self-Insured Plans – self-insured plans are provided by many employers and offer more flexibility than fully-insured plans. Employers can ensure that mental health benefits – both inpatient and outpatient – are provided as part of their plan and that out-of-network benefits are available, if needed. Employers can also lobby to include the Center of Excellence included as a in-network facility.
  • Trusts – Several IAFF affiliates participate in union-operated ERISA Trusts to provide health care to their members. Many of these have independent third-party administrators that allow them to operate out of network. If needed, single-case agreements can provide coverage for a member until the Center of Excellence becomes in network.

Knowing what benefits you have and what your health plan covers – in network and out of network – is critical. Insurance can cover part or all of the cost of treatment, depending on the policy. Not all policies cover mental health treatment or pre-existing conditions, so before taking out any policy, check it carefully and make sure you understand what it covers.

Your insurance card is the most important tool for using your insurance. Make sure your card is with you every time you get health care. Use this checklist to determine adequate coverage and for guidance on obtaining optimal benefits.

If you’re not sure what is or is not covered by your plan, contact Kelly Savage at [email protected] for assistance explaining your eligible coverage, copays and deductibles.

Participating Providers

Health Insurance Plan Review

Request a review of your local’s health insurance plan and benefits, recommendations on how to improve your coverage and assistance in negotiating benefit packages. Contact your district vice president for additional information.

Resources

Glossary of Health Insurance Terms
Mental Health Benefits: State Laws Mandating or Regulating

Choosing an Insurance Plan

Behavioral Health Coverage
Mental and behavioral health services are essential health benefits. Make sure your plan covers behavioral health treatment (such as psychotherapy and counseling), mental and behavioral health inpatient services, substance use disorder (commonly known as substance abuse) treatment. Specific behavioral health benefits will depend on your state and the health plan you choose.

If your employer offers a choice of insurance plans, check the mental health coverage of each option carefully during your open enrollment period. A more expensive plan that provides mental health coverage may ultimately save your members money over a low-cost plan without mental health benefits.

Open Enrollment
Open enrollment is a specified period of time each year when you can sign up for health insurance. Open enrollment periods are common for employer-provided health insurance, Medicare, individual market health insurance and health insurance exchanges under the Affordable Care Act (ACA).

Some employers allow you to sign up for or change other job-based benefits during open enrollment. Generally, you’re only allowed to make these changes during open enrollment. For example, you may be able to set up a flexible spending account or health savings account. A flexible spending account allows you to put aside pre-tax money to pay for eligible out-of-pocket expenses, such as psychotherapy, psychiatry visits and prescription medications. This doesn’t decrease the cost of the care itself, but you’ll save by not paying income tax on the money you use to pay for the care.

Negotiating Health Care 
Affiliates with collective bargaining rights are entitled to bargain over subjects that are considered mandatory to their employment contract, which includes health care.

Things to Consider

Is your employer self-insured, belong to a risk pool or is insurance directly from an insurance company? Knowing the difference can allow for creative benefit discussions.

Understand what the current benefit design allows for mental health, behavioral health and substance abuse disorders. Does the current benefit allow for inpatient or outpatient care? Is there a geographical restriction? Do you have to stay in network, in state or in your region? What happens if you chose to go out of network?

Be sure to understand — and obtain in writing — coinsurance, co-pays, deductibles, waiting periods or benefit maximums, as well as what diagnoses are covered under substance abuse disorder or mental health claims.

Are pre-existing conditions allowed and coverable? Do any benefit maximums apply?

What is the prescription drug coverage for mental health, behavioral health and substance abuse disorders? Are there limitations? Are psychiatric drugs covered?

What are the rules/laws with in your state that require benefit coverage?

What benefits are covered under the essential health coverage definition under the Affordable Care Act? Under other essential health benefits, such as preventive care, screenings for some mental health illnesses should be covered. Examples include screenings for depression, alcohol misuse and tobacco use.

Does your current plan(s) require your doctor to provide a referral or write a treatment plan? Does your plan(s) require pre-authorization? Remember every benefit has a cost of coverage associated with it.

Ask questions. If a member can pay out of pocket for needed services, there are likely plans that will cover those services.

Remember – 20 percent of policy holders make up 80 percent of the benefit cost. When it comes to mental and behavioral health, the percentages may be lower than the norm, so ask the question, what would it cost to cover them?

Family Medical Leave Act

Review your department’s leave policy, including leave donations, and legal rights under the Family Medical Leave Act (FMLA).

FMLA is a federal law that required covered employers to provide eligible employees up to a total of 12 work weeks of unpaid, job-protected leave in a 12-month period for specified family and medical reasons. It is unlawful for an employer to wrongfully deny FLMA leave to an employee with a qualifying medical reason, such as a “serious health condition that makes the employee unable to perform the functions” of his or her job. A serious health condition includes an illness, injury, impairment or physical or mental condition that involves an inpatient hospital stay or continuing treatment by a health care provider.

When an IAFF member requests FMLA leave for treatment at the Center of Excellence, the treating physician completes the required certification verifying that the member has been admitted for a serious medical condition as defined by FMLA and determined by the medical doctor.

The employer may require a certification issued by the employee’s health care provider regarding the condition, along with the appropriate medical facts and statement that the employee is “unable to perform the functions of the position of the employee.” Appropriate medical facts must be sufficient to support the need for leave and may include information on symptoms, diagnosis, hospitalization, doctor visits, prescribed medications and treatment regimen.

Employers may not ask health care providers for additional information beyond that required by the certification form.