Changing Your Elections
The health plan options you choose on your first day of employment at St. Jude and during the annual enrollment period will be in effect until the end of the current calendar year. If you have a qualifying change in your work or family status during the year, you are permitted to make certain changes to your elections. All changes must be made because of and consistent with your family status change. You must contact Human Resources–Benefits and submit the required documentation within 45 days of the event to ensure coverage. Examples of qualifying work and family status changes are:
- Your work status changes (e.g. part-time to full-time).
- You gain or lose a dependent (e.g. birth, marriage, divorce, death, etc.).
- Your dependent is no longer eligible.
- Your spouse loses his or her coverage.
There may be other situations in which you are able to make a change in coverage mid-year. Please contact Human Resources–Benefits if you have questions.
Coordination of Benefits
The St. Jude medical plan has a coordination of benefits (COB) feature that prevents duplication of benefits when you, your spouse or dependent children are covered by another medical and dental plan. Under this feature, the benefits provided by St. Jude will be coordinated with any benefits you or your dependents are eligible to receive under other plans according to certain rules. These rules determine which plan pays benefits first and ensures that the total benefits paid are no more than 100% of the allowable expenses for the claim. These rules generally provide that:
- If your dependent spouse has coverage under his/her own plan, coverage under that plan pays first.
- If your dependent child has coverage under both your plan and your spouse’s plan, the plan for the parent whose birth date comes first in the calendar year pays first.
Other COB rules may apply to your situation. Please call Human Resources–Benefits if you have additional questions.
Copayments (Copays) and Coinsurance
Certain services may require a copay. Copays are required for physician office visits, urgent care (minor medical centers), emergency rooms and prescription drugs. Copays do not count toward your deductible. Coinsurance refers to the division of the allowed amount to be paid on a claim (i.e., 70/30 means that 70 percent is to be paid by insurance and 30 percent is to be paid by you).
With both the Select and Choice PPO plans, you will have two different physician office visit copays—one for primary care physicians and a higher one for more expensive specialty physicians. The category of primary care physicians includes the following types of providers:
- General Practice
- Family Practice
- Internal Medicine
(Also includes Nurse Practitioner and Physician Assistant)
All other providers, such as cardiologists, dermatologists, etc., are considered specialists.
Except when a copay is required, you have to meet an annual deductible before the plan starts paying benefits for services. A deductible is the fixed dollar amount you pay for care before the plan begins to pay its share of the eligible expenses. You are responsible for 100% of your medical costs until you reach your annual deductible. In-network and out-of-network deductibles are separate and do not offset each other.
If You Choose to Add Either Spouse and/or Child(ren) Coverage
This level of coverage includes a maximum deductible per family for each calendar year. At least two, up to a maximum of three, covered individuals must fully meet their individual deductibles before the maximum deductible is met for a calendar year.
In addition to covering yourself, you also can choose to cover your eligible dependents (with proper documentation). In general, your eligible dependents include:
- Your spouse, if not covered as an employee; and
- Your children (natural, legally adopted, stepchildren and/or foster children) up to age 26, and if not covered as an employee; and
- Your children (natural, legally adopted, stepchildren and/or foster children) of any age who are physically or mentally disabled and rely on you for financial support (conditions for coverage are outlined in the Medical Summary Plan Document, which can be found on the St. Jude intranet).
If You and Your Spouse Work at St. Jude
If both you and your spouse are employed by St. Jude Children’s Research Hospital, you can select different options in the medical, dental and vision plans. However, you and your spouse cannot be covered as both an employee and a dependent. Only one of you can cover your dependent children.
When you enroll your dependents in the St. Jude benefits program, you may be asked to provide proof that the individuals you wish to cover are eligible dependents. If requested, you will need to provide the following:
- Spouse: a marriage certificate
- Child(ren): a birth certificate or other legal documentation that states you are legally the parent, foster parent, adoptive parent or stepparent; documentation indicating full-time student status or incapacity; or, child support documents
BlueCross administers the Select and Choice PPO plans, which use the "Blue Network P" network for providers in Tennessee and the “BlueCard PPO” network for providers outside Tennessee. It includes local and national providers, including the Methodist/LeBonheur, Baptist and St. Francis healthcare systems.
Services performed by a provider who is not contracted with St. Jude’s preferred provider network.
The out-of-pocket maximum includes the total payments toward eligible expenses that you pay for yourself or for your dependents including deductibles. Once you reach this limit, the plan will pay 100% of reasonable and customary charges for covered health services received during the remainder of that calendar year.
January 1 through December 31 for medical, dental and vision plans, as well as for the Flexible Spending Account plans.
A condition diagnosed and/or treated prior to the effective date of coverage or one for which a prudent person would have been treated.
Preferred Provider Organization (PPO)
A plan that allows a member to choose either a provider of their choice or a provider contracted with the network. Choosing an in-network provider will result in a higher percentage of the cost of services being covered.
The amount you and your employer pay for insurance coverage.
Any drug or medication that requires a physician order.
A generic drug is one approved by the U.S. Food and Drug Administration (FDA) that ischemically identical to its brand-name equivalent. To win FDA approval, the generic drugmust contain the same amounts of the same active ingredients as its brand-name equivalent.A generic drug typically is less expensive and is sold under a generic name for that drug(usually its chemical name). Because generic drugs are less expensive than their brand-nameequivalent, your co-payment usually is less, as well.
Reasonable and Customary Charges
The prevailing charge made by physicians, dentists, or other service providers for a similar procedure in a particular geographic area.
Self-Insured or Self-Funded Plan
The St. Jude medical program is self-insured (also called “self-funded”), meaning that the cost of each claim is paid directly by St. Jude—not by an insurance company. By self-funding, St. Jude assumes the risk, but is in turn able to adjust contribution rates and benefits according to plan usage. So, the less money spent on benefit claims, the more money available so that cost increases are kept to a minimum for our employees. St. Jude contracts with a third party administrator to provide administrative services.