| |
|
|
Home > Health Plan > B5 - Medical Benefits
COMPREHENSIVE MEDICAL BENEFITS
Click on any item to go directly to that section within this page
|
|
|
|
Your Plan pays a significant portion of your covered medical expenses and protects you from financial hardship in the event
of serious illness or injury. The Plan covers non-occupational illnesses and injuries only.
This benefit provides coverage for many common medical needs after you satisfy the Annual Deductible. Certain medical
expenses are paid before the deductible is satisfied.
Lifetime Maximum Benefit
Total payment for all covered expenses incurred during a covered individual’s lifetime is limited to $150,000. Lifetime refers
to a covered individual's duration of coverage under the Plan.
Top of Page
Annual Deductible and Benefit Rates
For most covered medical expenses, you must pay the first $250 of covered expenses each calendar year before the Plan
begins to pay benefits. This is called the Annual Deductible.
Once you have satisfied the $250 Annual Deductible, the Plan will pay the percentage specified in the
Summary of Benefits for the cost of covered medical expenses. You are responsible for
the difference.
Certain medical expenses are not subject to the Annual Deductible. These
expenses are paid immediately at 100% up to the benefit maximum.
Top of Page
Non-PPO Hospital Deductible
If you are admitted to a hospital that is not a BlueCross BlueShield PPO hospital and it
is not an emergency, you must pay a $350 deductible. This is in addition to the Annual Deductible.
Top of Page
Non-Compliance Deductible
If you are admitted to a hospital without having that admission pre-certified by
Health Information Services at the Benefits Fund Office, you must satisfy an additional $100 deductible. The additional
$100 deductible also applies to emergency care that results in hospital admission if Health Information Services is not
contacted within 48 hours of the admission.
If you have a scheduled surgery, either inpatient or outpatient, and you do not pre-certify the surgery by
contacting Health Information Services, an additional $100 deductible will be
applied before any benefits are paid.
If you have advanced diagnostic testing done without having the expenses pre-certified by
contacting Health Information Services, you must satisfy an additional $100
deductible before any benefits are paid.
Top of Page
Out-of-Pocket Limit
After you pay $2,000 (including the $250 Annual Deductible) in covered expenses during a calendar year, the Plan will
reimburse covered medical expenses at 100% of allowable charges for the remainder of that calendar year.
Expenses that do not count toward the out-of-pocket limit are:
Top of Page
PPO Providers—BlueCross BlueShield of Illinois
You have access to BlueCross BlueShield Participating Provider Option (PPO) hospitals and physicians under the Plan.
PPO providers offer discounts on services to you. When you use a PPO hospital, the Fund is charged a discounted rate.
When you use a PPO physician, you receive treatment at an agreed upon, discounted rate. The Fund shares these savings
with you by reducing your out-of-pocket costs. The Fund also pays a higher percentage of your expenses when PPO
hospitals are used.
Please note that charges by a non-PPO facility may be substantially in excess of the Plan’s usual and customary fees.
These excess charges are not covered under the Plan. Additionally, certain surgeries have limited benefits payable if
performed at a non-PPO facility (see next section below).
The BlueCross BlueShield PPO includes a large variety of first-rate hospitals and doctors, including world-renowned healthcare
providers. Why not use a PPO physician and hospital to control your health care costs?
To request a listing of BlueCross BlueShield PPO hospitals in Illinois, click on PPO Hospital
Listing. Or, go on-line and locate a PPO hospital or physician anywhere. Go to bcbs.com,
click on "Find a Doctor or Hospital" and follow the instructions from there. Or call BlueCross Blueshield at 800-810-BLUE (2583).
Top of Page
Special Laboratory Benefit
Covered laboratory testing can be obtained at no cost to you. Simply take your prescription order for the test(s) to any
of the conveniently-located Quest Diagnostic offices. Show them your UFCW Lab and Drug ID Card. Your tests will be run
and results sent to your physician without any cost to you.
To find a Quest Diagnostic office, go to questdiagnostics.com and click on
"Find a Quest Diagnostic location." Or you can call them at 1-800-377-8448 or the Benefits Fund Office at 1-800-621-5133.
Top of Page
Surgery at Non-PPO Facility
When certain surgeries are performed at a non-PPO facility, benefits will be limited to the Plan-defined
usual and customary fee or the following allowance, whichever is
lower:
| arthroscopy |
$ 3,200 |
| cataract |
$ 3,000 |
| colonoscopy |
$ 1,100 |
| cystourethroscopy |
$ 1,500 |
| elective abortion |
$ 750 |
| endoscopy |
$ 1,100 |
| epidural injections with fluoroscopy |
$ 1,300 |
| foot–hallux valgus |
$ 3,000 |
| foot–hammer toe |
$ 2,500 |
| foot–other |
$ 2,500 |
| gynecological |
$ 3,200 |
| joint implant removal |
$ 250 |
| nasal septum |
$ 3,500 |
| skin disorder repair |
$ 250 |
| tonsillitis-related |
$ 2,400 |
Top of Page
Pre-Existing Condition Limitation
If you had a pre-existing medical condition before you became covered by the Plan, benefits for that condition will be paid at
50%, up to a maximum of $5,000, until:
- 180 days of coverage have elapsed during which no medical care or treatment has been provided for that
pre-existing condition; or
- you have been continuously covered for 12 consecutive months.
A pre-existing condition is a sickness, injury, disease, or other physical condition that was diagnosed or treated by a
physician during the 6 months before your health coverage became effective.
Pregnancy is not a pre-existing condition for the purposes of this Plan.
This limitation may not apply, or may be shortened, if you show certification that you were covered under another group plan
immediately before you were covered under this Plan. If you cannot obtain such certification, the Plan will assist you. If
certification is unavailable, the Plan will consider other acceptable evidence.
Top of Page
Covered Medical Expenses
The Plan provides coverage for the following medical expenses, provided you are under the care of a licensed physician and
the covered services and supplies are medically necessary.
Benefits are payable as shown in the Summary of Benefits.
- Hospital services and supplies, including:
- room and board, up to the semi-private room rate
- specialty care unit charges
- Emergency Room charges
- Surgery and related charges
- Physician’s charges for surgery, radiotherapy procedures, or medical services
- Outpatient treatment, services and supplies for illness or injury
- Ambulatory surgical center services
- Diagnostic x-ray and laboratory charges
- X-ray, chemotherapy, radium, and radiation therapy
- Anesthesia and its administration
- Oxygen and its administration. Outpatient or portable oxygen is limited to $500 per calendar year plus the
one-time cost of an oxygen concentrator, if applicable.
- Professional ambulance transportation to and from a local hospital or between local hospitals.
Convenience transfers are limited to $300. Covered air ambulance expenses are limited to $15,000 in North America and
$25,000 elsewhere.
- Pregnancy. Federal law requires that benefits be provided to the mother for hospital confinement of at least 48
hours following a vaginal delivery or at least 96 hours following a cesarean section, unless the mother chooses to leave
the hospital sooner. Your doctor or hospital is not required to obtain authorization for a length of stay that does not
exceed 48 (or 96) hours.
- Durable medical equipment for therapeutic treatment. The purchase price for the following equipment is limited to:
| hospital bed |
$ 1.500 |
| custom wheelchair |
$ 12,000 |
| limb prosthesis |
$ 20,000 |
| scooter or other non-wheelchair transportation |
$ 2,600 |
| stander |
$ 3,000 |
| CPAP machine, complete |
$ 1,200 |
| CPAP machine replacement suplies for 6 months |
$ 200 |
Any expenses must be pre-certified by Health Information Services
at the Benefits Fund Office.
- Orthopedic or prosthetic appliances. The Plan will pay for the initial appliance, and after 5 years, one replacement for
each 5 years of continuous coverage. Covered items include:
- artificial limbs or eyes (limited to purchase price of $20,000)
- external breast prosthesis
- internal breast prosthesis (breast implant)
- penile implant, but limited to one per lifetime
- orthotic appliance
Cochlear implants are not covered.
- Medical supplies, trusses, braces or supports, casts, splints and crutches. The following supplies are limited to a
maximum per calendar year:
- 4 pairs of surgical stockings
- 1 wig, up to a maximum of $150
- 2 bras for a breast prosthesis
- Charges made by a registered nurse or licensed practical nurse, other than one who normally lives in your home
or is a member of your or your spouse’s immediate family. Only Home Health Care expenses that are
pre-certified by Health Information Services at the Benefits Fund Office
will be covered.
- Home health care. The Plan pays up to $10,000 per calendar year for the following services when provided by a
Home Health Care Agency:
- skilled nursing care by, or supervised by, a licensed nurse; home aides are not covered
- administration of IV therapy
Covered medical expenses are limited to expenses that are pre-certified by
Health Information Services at the Benefits Fund Office. Each visit by a member of the home health team will count
as one visit.
- Physical theapy. Benefits are limited to a combined maximum of $2,500 per calendar year for the following:
- chiropractic treatment of the back, neck, spine or vertebra, for conditions due to subluxations,
strains, sprains and nerve root problems (limited to $1,500 per calendar year); and
- osteopathic manipulation, physiotherapy, prolo therapy, acupuncture and physical medicine
services
- Occupational therapy. Benefits are limited to $2,500 per calendar year.
- Speech therapy. Benefits are limited to $2,500 per calendar year.
- Cardiac rehabilitation. Benefits are limited to $1,000 per event.
- Organ/tissue transplants. Benefits are limited to $100,000 per transplant, including related charges up to 120
days after a transplant procedure; donor-related expenses are not covered.
- Varicose vein treatment. Benefits are limited to a lifetime maximum of $2,500 per leg, except for ulcerated
conditions.
- Reconstructive treatment because of an accidental injury or congenital disease or anomaly that results in a
functional defect or deformity from trauma, infection or other disease of the involved body parts
- Dental treatment due to accidental injury to sound and natural teeth within one year from the date of the accident
- Voice communication machines. The Plan pays up to a $7,500 per person lifetime maximum.
Top of Page
Other Covered Medical Expenses
These covered services are subject to the rules and limitations explained under each item.
These expenses are NOT subject to the Annual
Deductible—benefits are payable immediately at 100% up to the specified maximum:
Mammography. Benefits are payable up to $130 per calendar year for a screening mammogram and its interpretation
to detect the presence of breast cancer in women, according to the following schedule:
| Age 35-39 |
one baseline mammogram |
| Age 40 and up |
annually |
Expenses in excess of $130 are payable at 80% after the Annual Deductible.
Preventive Care. You are eligible for benefits up to $50 each calendar year for:
- a routine physical exam
- a PAP test
- complete blood count, cholesterol test, multi-channel blood test and urinalysis
- colon cancer screening if age 50 or older
- Prostatic Specific Antigen (PSA) blood test
Expenses in excess of $50 are payable at 80% after the Annual Deductible.
These expenses ARE subject to the Annual Deductible:
Bone Density Scan. Benefits are payable once every four calendar years if you are age 45 or older.
Mental Health. Benefits for mental health treatment are subject to the following maximums:
| inpatient |
limited to 10 days in any one calendar year |
| outpatient |
Plan pays 50% for up to 20 visits per calendar year |
Substance Abuse. Benefits for all covered charges incurred for substance abuse treatment are limited to:
| combined inpatient and outpatient maximum |
$5,000 lifetime maximum |
Obesity Surgery. Charges for surgical treatment of obesity must be
pre-certified by Health Information Services at the Benefits Fund Office and the following conditions must be met or the
surgery will not be covered:
- You must have a Body Mass Index (BMI) of 50 or greater, must have achieved adult height, must be older
than age 18, and must have no medical or psychiatric contraindication to undergoing bariatric surgery.
- You must have undergone a medically-supervised weight-loss program acceptable to the Board of Trustees.
The program must include physician supervision for a period of not less than six months and concurrent evaluation and
treatment by a registered dietician (R.D.). The supervising physician must not perform bariatric surgery.
- You must have been evaluated by a mental health professional skilled in the evaluation and treatment of
persons with morbid obesity, and, if appropriate, must have received treatment for behavioral or psychiatric co-morbid
conditions. Documentation of all evaluations and treatment must be available for review by the Benefits Fund Office.
Once the above conditions have been met, the surgery must be provided by a board-certified surgeon experienced in the
treatment of bariatric surgical patients and be performed at a facility acceptable to the Board of Trustees and the Fund
Administrator.
If the surgery or the surgeon is not approved, the Plan will not cover any expenses incurred.
Intentionally Destructive Act. Benefits are payable at 50% up to $5,000 per event for the care and treatment of an
illness or injury resulting from an intentionally destructive act, including a self-administered overdose, that is not attributable to
a medical condition or to an act of domestic violence.
Hearing Aid. Benefits are payable at 80% up to $500 in a five consecutive year period for covered charges for a
hearing examination and hearing aid..
Covered charges include the following hearing expenses:
- an otologic examination performed by a physician
- an audiologic examination performed by a physician or a licensed audiologist
- the hearing aid (monaural or binaural) prescribed as a result of an examination. This generally includes ear mold(s), the
hearing aid instrument, the initial batteries, cords and other necessary ancillary equipment.
- a follow-up consultation within 30 days following the delivery of the hearing aid
The following hearing expenses are not covered:
- expenses for more than one hearing examination without a hearing aid being obtained
- replacement batteries
- charges for repairs, servicing and alterations
Skilled Nursing Facility Care, Rehabilitation Therapy and Hospice Care.
Medically necessary care in a skilled nursing facility, rehabilitation therapy and
hospice care are covered if pre-certified by Health Information Services at the
Benefits Fund Office. The Plan will not consider these expenses medically necessary and will not cover them if you do not
receive pre-certification for them.
Women's Health and Cancer Rights Act of 1998. Under federal law, group health plans
that provide medical and surgical benefits in connection with a mastectomy must provide benefits for certain reconstructive
surgery. If you are receiving benefits under the Plan in connection with a mastectomy and elect breast reconstruction, federal
law requires coverage in a manner determined in consultation with the attending physician and the patient, for:
- reconstruction of the breast on which the mastectomy was performed;
- surgery and reconstruction of the other breast to produce a symmetrical appearance; and
- prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas.
Top of Page
What's Not Covered
Expenses that are not covered under the Comprehensive Medical Benefit include but are not limited to the following:
- custodial care, educational and training care
- cosmetic treatment or complications thereof
- expenses for hormone therapy, artificial insemination or any other direct attempt to induce or facilitate fertility or
conception
- genetic testing, except for amniocentesis, government-mandated neonatal testing, and testing for the purpose of
determining the medical appropriateness of therapy for newly-diagnosed breast cancer
- charges related to a surrogate pregnancy
- naturopathic or homeopathic services and substances
- personal hygiene, comfort or convenience items such as air conditioners and humidifiers or physical fitness
equipment
- over-the-counter supplies
- foods and nutritional supplements including, but not limited to, home meals, formulas, diets, vitamins and minerals
(whether they can be purchased over-the-counter or require a prescription), except when provided through a feeding
tube as sole nutrition
- shoes, for any reason
- wigs or toupees except when made necessary due to loss of hair resulting from treatment of a malignancy or
permanent loss of hair from an accidental injury (limited to one per calendar year up to a maximum benefit of $150);
hair transplants, hair weaving or any drug if such drug is used in connection with baldness
- breast reduction surgery except for reconstruction due to breast cancer
- expenses related to sexual reassignment
- skin removal surgery for any reason
- immunizations
- routine screening tests, except as otherwise noted
- routine foot care such as the cutting and trimming of toenails
- marriage counseling or treatment for anti-social behavior which is not the result of a mental or nervous disorder
- services or supplies for weight reduction by diet control or behavior modification, with or without drugs. However,
physician visits for weight loss for morbid obesity are covered.
- transportation other than local ambulance service and covered air ambulance
- expenses for and related to travel for you or a physician
- donation of an organ or tissue
- blood storage charges except for use for an anticipated covered medical condition for a period not to exceed six
months
- blood donated by family members or others specifically for another patient's use
- expenses for home blood pressure monitoring or home uterine monitoring equipment, for any reason
- muscle stimulators in excess of $500
- cochlear implants
- snoring correction devices, unless sleep apnea has been diagnosed
- repair of, or operating supplies for, durable medical equipment
- services performed on or to the teeth, nerves of the teeth, gingivae or alveolar processes except for tumors or cysts
or unless resulting from an accidental injury to sound natural teeth
- eye refractions, eyeglasses or their fitting
- procedures for surgical correction of myopia and/or other refractive errors
- vision therapy
- non-prescription (over-the-counter) drugs or medicines
- vitamins, including vitamins requiring a written prescription. However, pre-natal vitamins are covered.
- smoking cessation products, including those requiring a prescription
- contraceptives or medications for contraception, including medications or contraceptives requiring a written
prescription, regardless of intended use
- charges for infection control and medical waste disposal
- anything excluded under General Exclusions and Limitations.
Top of Page
|
|
