Frequently Asked Questions

Browse through some of the questions commonly asked.  If you have any questions not answered below, please contact us at 419.255.5314 or lfurry@ameritech.net.

FAQ CATEGORIES

DENTAL
SPOUSAL
MEDICAL
ELIGIBILITY
PROVIDER STATEMENTS
SUBROGATION
PPO PROVIDERS
REFERRALS
VISION
PRESCRIPTIONS
ANNUAL ENROLLMENT FORM

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DENTAL

• Do we have to go to a Dentist in the Frontpath network?
• No, the Health Plan does not have a Dental Network.  Members can go to any Licensed Dentist.
• How much does the Plan pay for fillings and crowns?
• Fillings and crowns are paid at 80%, after an annual deductible of $25 is met.
• What is our Dental maximum?
• We have a calendar year maximum of $1250, per covered dependent.
• How much does the Plan pay for orthodontics?
• We pay 50% of the treatment up to the lifetime maximum of $2000.
• Does the Plan cover orthodontics for adults?
• No. Orthodontics is covered for dependents up to the age of 19.
• Are Dental Implants covered on our Plan?
• Implants require a predetermination. If approved, implants would be covered under the Dental Restorative benefit at 80%.
• Are mouth guards covered?
• Yes. The Plan pays 50%, once a lifetime. However, adjustments or replacements are not covered.
• Are veneers covered?
• No.
• Are fluoride treatments covered for adults?
• Yes. Adults are allowed 1 treatment per calendar year, paid at 100%.
• Do I have to go to the dentist exactly 6 months apart for my exam?
• No. You are allowed 2 visits per calendar year and they do not have to be 6 months apart.
• Is there anyway to get additional payment for the restorative work, outside the $1250 calendar year max?
• No. There is a $1250 calendar year maximum for each eligible member.
• My son is going to school to be a Dentist and I want to go to him as a patient. Will the Health Plan pay for the visits?
• No. You cannot go to a family member even if they are a licensed dentist or physician.

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SPOUSAL

• I have my own insurance and my husband is the Firefighter, do I have insurance on his plan?
• Yes. Spouses are primary on their own insurance and secondary on the Toledo Firefighters Health Plan.
•  I am offered insurance through my place of employment; do I have to take it? Even if I have to pay for it?
• Yes. If you are offered insurance through your employer, you must take ALL that is available, even if at a cost.

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MEDICAL

• I have co-pays and deductibles on my insurance and I want to know if the Health Plan will pay anything towards those?
• Yes. The Plan picks up any co-pays, coinsurance, and deductibles, as long you follow the guidelines of your Primary Insurance.
• 18. I need Physical Therapy, what do I do?
• Your physician must prescribe physical therapy for you. All therapy needs to be precertified with HealthCare Strategies for payment.
• 19. Are flu shots covered?
• Not through the Health Plan. Please contact EMS directly for information.
• 26. I just found out I’m pregnant, do I need to do anything?
• Yes, within the first 3 months, you must contact HealthCare Strategies to certify your pregnancy. The # can be found on the back of your Health Plan Card.
• 27. I just had a baby, how do I add him/her to my plan?
• You must add your new baby within 31 days of birth. Contact the Health Plan office or stop in so you can update your enrollment form.

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PPO PROVIDERS

•  My insurance company won’t cover my doctor because he is not in the network. Will you pay if I choose to go to him?
• If your Primary insurance does not pay anything because you went out-of-network, then we will not pay anything on the claim. If the insurance company pays the claim at a reduced rate, then we will coordinate the benefits.

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REFERRALS

•  Do I need a referral to go to a specialist?
• No, the Health Plan does not require referrals.

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VISION

•  Why type of Vision Benefits do I have?
• We now utilize SPECTERA for our Vision Benefits. You will contact Spectera directly for all benefit information and questions. You will NO LONGER submit paid receipts to the Health Plan office.

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PRESCRIPTION

•  Is there a program where I can monitor my Drug prescriptions?
• Yes, that program is called RxEOB. Please visit the Plan website at www.tffhp.org for information on activating your account.
•  What are my prescription copays?
• $5 for generic; $15 for Brand Formulary: $30 for Brand non-formulary. Please visit the plan website at www.tffhp.org to activate your RX account (RxEOB) for complete benefit information.

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PROVIDER STATEMENTS

•  I keep receiving Provider Statements in the mail saying I owe a lot of money, should I just pay the bill?
• If you are uncertain if you owe the amount billed, please contact the Plan Office directly. Do not pay a bill until you are sure it is the correct patient balance.
•  I’m receiving threatening statements from my Physician because they said my insurance hasn’t paid.
• Please call the Plan Office once you receive the FIRST statement, do not wait. The sooner we have the information, the sooner we can get the information we need to process the claim.

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SUBROGATION

•  I was in a car accident, who is responsible for the bills?
• All auto accident claims must be filed with the auto insurance company. The Health Plan is not responsible for these claims. Please call the Plan Office directly, if you have been involved in an accident.

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ANNUAL ENROLLMENT FORM

•  Why do we have to fill out a new enrollment form every year?
• Information changes and this is the best way for the Health Plan to stay on top of this. Re-enrollment is required each year.

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ELIGIBILITY

•  My son is turning 19 next month, will he be covered under the Plan still?
• Dependents who are ages 19 – 23 are covered under the Health Plan as long as they are enrolled as full-time college students. Full time is considered 12 credit hours.
•  How do I prove my son is a full-time student?
• Each quarter/semester, you must submit proof to the Plan that your dependent is a full-time student. This may be in the form of a class schedule, letter from the school, etc.
•  I just got married and I would like to add my step-son to my policy?
• The Health Plan has requirements that must be met in order to add stepchildren. Please contact the Plan office directly to review your case.