Eligible Dependents/Qualified Dependents
If you have elected Family Coverage, your eligible dependents are:
- your lawful spouse of the opposite sex;
- your unmarried children who are under 19 years of age, dependent on you for more than one-half of their support and
who reside with you in a regular parent-child relationship for more than one-half of each year or who are otherwise specified
in a Qualified Medical Child Support Order (QMCSO). If you are a non-custodial parent due to divorce or legal separation,
your child must reside with either you or the other parent for more than one-half of each year.
Your unmarried children include:
- your natural children;
- your legally-adopted children or those for whom adoption proceedings have been started and who have been placed in
your home by a licensed placement agency for the purpose of adoption;
- your step-children if both the child and the child’s natural parent live with you; and
- children for whom you have legal responsibility as the result of a court order if the child is your first degree relative.
If your dependent is a full-time student attending an accredited school and is financially dependent on you for more than one-half
of their support, he or she will be eligible to age 23. He or she must reside with you for more than one-half of each year. A
temporary absence to attend school is permissible if the child returns home when school is not in session. Proof of full-time student
status for each school semester is required for children age 19 and older. For example, each semester obtain proof of attendance
and number of enrolled credit hours for that semester by requesting written verification from the school registrar’s office; forward
this proof to the Benefits Fund Office each semester. Unless a student continues to be enrolled, coverage usually ends January
31 for the fall semester and September 30 for the spring semester.
If a dependent was covered up to the date coverage would otherwise end because of reaching age 19, and if on that date the
dependent:
- is incapable of self-support due to mental retardation or physical handicap which began before the child attained age 19;
- is dependent upon you for more than one-half of his or her financial support and maintenance; and
- resides with you permanently and regularly for more than one-half of each year or lives in a treatment center,
then that dependent will be covered for so long as the incapacity and dependency continue, but not beyond the date on which
your coverage ends.
Legal documentation of your dependent’s status, such as by an original registered marriage certificate, certified government-issued birth
certificate or divorce decree, may be required by the Benefits Fund Office.
If both husband and wife are eligible as full-time employees, their dependent children are covered as dependents under both the
wife and husband.
Medically Necessary
Services, supplies, treatments and confinements that are:
- generally recognized by physicians as effective and essential for treatment of the injury or sickness for which it
is ordered;
- provided at the appropriate level of care and in the most appropriate setting based on the diagnosis;
- based on generally recognized and accepted standards of medical practice in the U.S. and is the type of care that
could not be omitted without adversely affecting the patient’s condition or the quality of medical care; and
- when hospital-confined, a service or supply is a medical necessity only if the diagnosis and treatment cannot be
safely provided on an outpatient basis.
Services, supplies, treatments and confinements are not considered medically necessary if they are:
- Experimental.
- Investigative or primarily limited to research in their appplication to the injury or sickness.
- Primarily for scholastic, educational, vocational or developmental training.
- Primarily for the comfort, convenience or administrative ease of the provider or the patient or the patient's family or
caretaker.
The fact that a physician or other health care provider orders or recommends services, supplies, treatment or procedures
does not in itself make them medically necessary.
Retail Prescription Program
The Prescription Drug Benefit is managed by NMHC/Rx, a prescription benefit manager with a large network of pharmacies, called
"participating pharmacies." You receive the highest level of benefits when you fill your prescription at a participating retail pharmacy.
Usual and Customary Charge and Plan-Limited Allowance
Payment of benefits is limited to the usual and customary charge for covered services or to the Plan-limited allowances for certain
surgeries or for certain equipment.
For treatment in the geographic area served by the PPO, the negotiated discounted fee amounts are the usual and customary
charges. For treatment outside the area served by the PPO, the usual and customary amount is determined based on the average
charge made by the majority of providers located within the geographic area.
The usual and customary charge for durable medical equipment and for home health care is the charge negotiated between the
Plan and providers who have agreed in writing to provide the equipment or services.
The Plan-limited allowance applies to
- certain surgeries when performed at a non-PPO facility; and
- the purchase price for certain medical equipment.