Chapter 8: Health Care Support
INTRODUCTION
You are covered by the AmeriCorps*VISTA Health Benefits Program. The benefits under this program are limited, and they do not provide coverage for health issues related to illnesses or injuries that existed prior to service as an AmeriCorps*VISTA member. The AmeriCorps*VISTA Health Benefits Program is not a health insurance policy; consequently, many requirements for (and benefits of ) health insurance do not apply.The benefits under this program and related procedures are explained in detail in AmeriCorps*VISTA's Member Health Care Guide. This guide and a health identification card are given to you shortly after you are sworn in as an AmeriCorps*VISTA member.
In case of an accident or illness, you must notify your project supervisor. If hospitalization or extended absence from the project is required, the project supervisor must immediately notify the Corporation State Office.
COVERAGE
Coverage begins automatically on your first day of AmeriCorps*VISTA Pre-Service Orientation and applies only to you. It does not extend to your spouse or other dependents. Coverage ends at midnight on the date of your termination as an AmeriCorps*VISTA member or trainee.
These benefits may be affected by restrictions on payment for pre-existing conditions, as well as other exclusions to coverage. The exclusions are set forth in the Member Health Care Guide distributed by AmeriCorps*VISTA's health plan contractor.
If you have questions concerning coverage for certain medical procedures, contact the appropriate department of AmeriCorps*VISTA's health plan contractor- listed in the health care guide and on the health identification card-via the toll-free customer service telephone number: 866-699-4186. The health plan contractor's staff will provide information about eligibility for care.
OTHER HEALTH COVERAGE
The AmeriCorps*VISTA Health Benefits Program is not an insurance policy. You may continue your own private health insurance during your service. Members with dependents may wish to continue private coverage because spouses and dependents are not covered under the AmeriCorps*VISTA Health Benefits Program. Also, members with pre-existing conditions may wish to continue private coverage to ensure that they will have the type and amount of coverage they need during and after service. If you decide to maintain a private insurance policy, AmeriCorps*VISTA's health plan ordinarily will pay only for those benefits not paid by your private plan and that fall within the guidelines for eligible expenses.COORDINATION OF BENEFITS
If you are covered by more than one health plan, most health care programs, including the AmeriCorps*VISTA health plan, contain a coordination of benefits provision. This provision is used when a member is eligible for payment of claims under more than one health program. Coordination of benefits assures that the covered expenses will be paid and that the combined payments of all the programs do not amount to more than the actual cost of care.Coordination of benefits prevents duplicate payments and helps to hold down the cost of health care coverage. Members with additional coverage are required to use their private plan as the primary insurer to the maximum extent of coverage before submitting claims to AmeriCorps*VISTA's health plan contractor for payment.
SUBROGATION FOR MEDICAL CARE EXPENSES
If you are in a car or other accident while serving as an AmeriCorps*VISTA member, the Corporation may initially pay for your medical care. If that happens, and you then collect from the insurance company of the person who was at fault (or from your insurance company if the person at fault has no coverage), the Corporation has the right to recover from you the cost of whatever medical care it had paid for. This situation is known as subrogation. In other words, if you are injured or become ill through the fault of another person not with the Corporation and that person's insurance company, or your insurance company, settles with you, the Corporation has the right to recover from you the cost of any health care it has paid, irrespective of the reason for the settlement. For a more complete description of subrogation, consult the Member Health Care Guide.MEDICARE AND MEDICAID COVERAGE
AmeriCorps*VISTA's Health Benefits Program is considered the primary provider of benefits for members who also are covered by Medicare, Medicaid, or other similar federally funded government health benefits programs. Therefore, members who are eligible for coverage under such programs should first send their claims to AmeriCorps*VISTA's health plan contractor.CONVERSION PRIVILEGE
AmeriCorps*VISTA's health benefits coverage ends at midnight on the day you end service or are terminated from the AmeriCorps*VISTA program. When you end your service, you may convert from the health plan provided by the AmeriCorps*VISTA contractor to a designated private health insurance plan as described in the Member Health Care Guide. You must make and implement your decision to convert to this private insurance plan within 31 days of the date of termination from service. The conversion options are expensive and should only be explored if you cannot find lower cost insurance. If you exercise the conversion option, the private plan becomes effective on the day after termination from AmeriCorps*VISTA service.
FEDERAL EMPLOYEES' COMPENSATION ACT
Under section 415(b) of the Domestic Volunteer Service Act of 1973, as amended (42 U.S.C., § 5055), AmeriCorps*VISTA members are considered employees of the federal government for purposes of coverage under the Federal Employees' Compensation Act (FECA), which is administered by the Office of Workers' Compensation Programs (OWCP) of the U.S. Department of Labor. The Department of Labor's OWCP office is solely responsible for the adjudication of FECA claims. This means that members are eligible for certain benefits in certain situations, and eligibility is determined by OWCP, not the Corporation.
BENEFITS
FECA provides compensation benefits for an illness or injury if it is judged by OWCP to be service-related (i.e., caused or aggravated by the performance of a member's assignment). Coverage by FECA begins for AmeriCorps*VISTA members after they are enrolled (sworn in) in the AmeriCorps*VISTA program. You are not covered by FECA, however, if the injury or disability results from your own misconduct, intoxication, or willful intent to bring about injury or death to yourself or others.Benefits approved under FECA begin after termination from AmeriCorps*VISTA service and include payment for continuing medical care and compensation for wage loss and permanent impairment of certain members or functions of the body in the event of a service-related disability. FECA also contains provisions for payment of certain death benefits, such as shipment of the body, funeral and burial costs, and survivor's benefits if the member's death results from an injury or illness sustained in the performance of official project duties.
CLAIMS PROCEDURES
If you are injured or experience an emergency illness related to your assignment, the project supervisor and the Corporation State Office must be notified immediately. To protect your right to apply to OWCP for compensation, you need to complete the form (CA-1 or CA-2) that the Corporation State Office will provide you.
- The CA-1 form, Notice of Traumatic Injury, should be filed when an accident or physical injury occurs during performance of duties.
- The CA-2 form, Notice of Occupational Disease or Illness, should be filed when a disease or illness is suspected of being caused by job performance.
Although an illness or injury may not appear to be serious enough to result in compensation eligibility, you should complete the claim forms to protect your rights in case future complications develop. You have up to three years from the date of injury or up to three years from the date you realize your assignment caused an injury to request your completed form be filed with OWCP.
The Corporation State Office will:
- Advise and assist individual claimants regarding the preparation, submission, and follow-up of their respective FECA claims
- Provide appropriate assistance in compiling and submitting all pertinent information relating to FECA claims
Parts of these forms require completion by the sponsoring organization. Notify the Corporation State Office if you need assistance in receiving these forms back from your former sponsoring organization.
Submit all FECA claims and relevant material to:
AmeriCorps Health Benefits Office
Corporation for National and Community Service
1201 New York Ave., NW
Washington, DC 20525
APPEAL PROCEDURE
You may petition any claim rejected by OWCP by following the appeal rights process outlined in the OWCP information guide, When Injured at Work. This guide and other resources about claims under FECA are available on the Division of Federal Employees' Compensation Home Page at www.dol.gov/esa/regs/compliance/owcp/fecacont.htm.DEATH BENEFITS
In the event of a member's death during service, the next of kin or designated beneficiary is entitled to the following:
- Coverage of expenses incurred at the place of death (ambulance service, transportation of the body, etc.)
- Funeral and burial benefits from either the Corporation (to a maximum of $1,000) or from OWCP if the death is found to be servicerelated
- Shipment of member's personal effects
- Unpaid compensation or reimbursement owed to the member
- Life insurance (if the member had enrolled in the group policy)
- Any benefits available to spouse or dependents from OWCP if the death is determined to be assignment-related
