Benefits » Health Insurance » Definity Health
Like other health plans, LANS/LANL Definity Health provides access to a large national network of providers and care facilities. However, Definity Health gives you choice and control over your health care decisions and expenditures by combining a high-deductible medical plan design with an ancillary Health Reimbursement Account (HRA). A HRA is a set of funds put aside for you by LANS/LANL to help you cover medical plan expenses that require some element of cost-sharing. For example, these expenses include deductibles and copayments. In addition, if you have funds in your HRA, it may be used to pay for certain medical expenses not covered under the Plan such as:
The Definity Health is made up of three components:
When you enroll in Definity Health, LANS/LANL will allocate funds to your HRA. The amount allocated to your HRA will depend upon which level of coverage you elect, as follows.
Your HRA funds help you pay a portion of your out-of-pocket costs under the plan, including annual deductibles and coinsurance.
If you do not use all of the funds in your HRA during the calendar year and you reenroll in Definity Health for the following year, the balance remaining in your HRA will carry forward to the following year, for up to a three-year cap on rollover expenses. If you choose not to reenroll in Definity Health for the following year, you will continue to have access to any funds remaining in your HRA until March 31 of the following year. For example, you or your provider can submit claims through March 31 of Year 2 for eligible expenses that you incurred during the plan year, January 1 through December 31 of Year 1.
Definity Health benefit uses the PPO network of physicians and allows you to go out of network for your healthcare needs. You are required to meet a large deductible and are given the HRA to use for all medical expenses.
The cost of preventive health care is covered at 100% when using an in-network physician and does not reduce your HRA or count towards meeting your deductible. Preventive care includes well care for children up to age 2 and adults. Once the deductible is met, you pay only 10% for all other in-network medical services and 40% for any out-of-network coverage. (Out-of-network, out-of-pocket limits are higher because costs cannot be controlled for nonnetwork providers.)
PPO |
|||
| Calendar-Year Deductible* | Out-of-pocket Maximum | Office Visit | |
|---|---|---|---|
| In-network | Employee: $1,500 Employee & Adult: $2,250 Employee & Child(ren): $2,250 Family: $3,000 |
Employee: $2,750 Employee & Adult: $4,125 Employee & Child(ren): $4,125 Family: $5,500 |
10%** (no charge for child under 2) |
| Out of network | Deductible is combined for in-and out-of-network | Employee: $8,500 Employee & Adult: $12,750 Employee & Child(ren): $12,750 Family: $17,000 |
40% |
| * Amounts include HRA dollars. | |||
| ** HRA and deductible waived for In-Network. | |||
All the new benefits provided in the Lab's benefits plans are offered by the Definity Health , including hearing aids, surgery for morbid obesity, 20 visits each for physical therapy, occupational therapy, and speech therapy, as well as coverage for Christian Science practitioners.
Your HRA is tracked on UnitedHealthcare's Web page. There, you can check balances and expenditures on your account. You can also find information on selecting physicians, researching health care needs, and determining usual and customary charges for medical procedures.
To use the Web site, you will need to establish an account using a PIN number, which provides 24-hour access to the portal. You can also call a 24-hour nurse line to obtain guidance for minor emergencies or other health care questions.
The Benefit Eligibility Level Codes (pdf) for Definity NM are 1, 2, and 3. The areas covered are restricted to zip codes in New Mexico.
New Mexico does not recognize "common law" marriages; therefore, only a legal spouse or eligible domestic partner may be enrolled in LANS sponsored health and welfare plans.
You may enroll yourself or an eligible family member in a LANS-sponsored medical plan if you are a newly-hired employee, have a qualified change of status, or during Open Enrollment, which is held at the Lab each November, with coverage effective January 1st of the following year.
If you are newly hired, you have a period of initial eligibility (PIE) during which you may enroll yourself and your eligible family members. Your PIE starts the day you become eligible—usually on your date of hire—and ends approximately 31 days later.
To enroll, submit a completed insurance enrollment form (pdf) to the Lab’s Benefits Office within 31 days of your PIE.
You may become eligible for LANS-sponsored benefits if you change employment status (e.g., change from contractor to LANS or limited benefits to full benefits). When this happens, contact the Lab's Benefits Office immediately by calling 505-667-1806 or e-mail the Benefits Office to determine when your PIE begins and to register for a benefits presentation. You will have a 31-day PIE from the date your employment status was changed
Families change and grow due to marriage, birth or adoption of children, and other events. If enrolling in a medical plan because of a family status change (e.g., marriage or birth of a child), you must request enrollment within 31 days from the date of the qualifying event (e.g., date of marriage or date of the child's birth).
To enroll, contact the Lab’s Benefits Office at 505-667-1806 or e-mail the Benefits Office.
If you are not enrolled in a medical plan, you and your eligible family members may enroll during Open Enrollment, which is usually held in November for coverage effective January 1st of the following year.
If you and/or an eligible family member involuntarily lose other employer-sponsored medical insurance coverage, you may enroll in one of LANS’s medical plans. A new PIE starts the day you lose coverage. You must furnish proof that other employer group coverage was lost.
To enroll e-mail the Benefits Office or call 505-667-1806.
If you are going on or returning from a change of station or extended travel and will be moving in or out of a service area, you may be able to change your insurance plan. Contact the Lab’s Benefits Office at 505-667-1806 or e-mail the Benefits Office about this change.
If you missed your PIE, you can still enroll in medical coverage at any time by submitting an enrollment form to Benefits; however, your medical coverage won’t go into effect for 90 calendar days from the day you submit your form.
LANL employees enrolled in a UnitedHealthcare plan can now easily access information on claim status. This on-line service is provided by UnitedHealthcare and allows you to:
Insurance card. If you don’t receive your UnitedHealthcare card within several weeks of enrollment (45+ days) contact UnitedHealthcare directly at 1-800-603-3816.
Contact customer service. To change your PCP, inquire about claims or covered services contact the UnitedHealthcare LANL representative.
Dispute with UnitedHealthcare. You should first contact UnitedHealthcare customer service directly at 1-800-603-3816 to resolve the issue. If you are unsuccessful in resolving the issue through this route, you can meet with the LANL UnitedHealthcare representative.
This is only an overview of the Definity Health medical insurance plan. For full details, refer to the Definity Health Summary Plan Description (pdf).
Questions? Contact the Lab's Benefits Office at 505-667-1806.