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Home > Health Plan > Surgical Benefits
SURGICAL BENEFITS AND INFORMATION Some plans do not include every benefit mentioned. Refer to your plan booklet to verify which benefits are included in your plan.
Benefits are payable for surgery and related charges for conditions covered under the Plan. The benefit rate is:
Certain penalties apply if a non-PPO hospital is used on a non-emergency basis:
BlueCross BlueShield Participating Provider Option (PPO)
When you use a PPO hospital, the charges are substantially discounted and paid at the higher 85% benefit rate. Many quality
hospitals and physicians are a part of the network, including world-renowned healthcare providers.
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. Expenses that are not covered by the Health Plan are not subject to a discount.
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).
A Word of Caution Regarding Non-PPO Surgical Centers
A large number of appeals are filed each year by employee-members who have surgery performed at outpatient surgical
centers that are not a part of the BlueCross BlueShield PPO network. These centers often charge twice the amount that a
PPO hospital or surgical facility would charge. Remember, Plan benefits are limited to the usual and customary fees that are
normally charged. There is no reason to be exposed to thousands of dollars of personal liability when a non-PPO
facility is used. Why use such a clinic when you could have your surgery at a prestigious university hospital for half the cost?
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).
Surgery at Non-PPO Facility
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.
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:
$ 3,200 $ 3,000 $ 1,100 $ 1,500 $ 750 $ 1,100 $ 1,300 $ 3,000 $ 2,500 $ 2,500 $ 3,200 $ 250 $ 3,500 $ 250 $ 2,400
Pre-Certification Required
To receive your full benefits, the Benefits Fund Office must be notified of non-emergency surgeries. The nurses in
Health Information Services at the Benefits Fund Office will be available to answer any
questions you may have regarding coverage and to help insure that you comply with Plan requirements regarding second
surgical opinions.
If you do not pre-certify your surgery, an additional $100 deductible will be applied before any benefits are paid.
Second Opinion Requirement
You may be required to obtain a second opinion in order to receive full benefits. The types of surgeries that require a second
opinion are:
If a second opinion is not obtained, benefits will be paid at 50% after satisfaction of the $250 Annual Deductible.
The second opinion must be provided by a medical doctor who is board-certified in the appropriate medical specialty as
determined by the Board of Trustees. Neither the doctor nor anyone in his or her office may be financially involved with the
office of the doctor who will perform the surgery. To be certain the second opinion doctor meets the Plan requirements, be
sure to contact Health Information Services at the Benefits Fund Office.
Pre-Surgery Testing
Pre-surgery testing includes necessary diagnostic x-rays and lab tests performed prior to surgery. These test expenses are
payable at 80% after satisfaction of the $250 Annual Deductible.
Obesity Surgery
Before incurring expenses for surgical treatment of obesity, you must contact Health Information
Services for approval. If certain conditions are not met and if the expense is not approved, it will not be considered
medically necessary and the Plan will not cover it.
All of the following criteria must be met:
If the surgery or the surgeon is not approved, the Plan will not cover any expenses incurred.
Dental Surgery
Generally, dental surgery, including anesthesia, is covered under the Dental Benefit when surgery is performed in a dentist's
office or at an outpatient clinic. However, if it is medically
necessary for you to have dental surgery in the hospital, the Plan will pay 50% of the covered hospital charges up to a
maximum of $5,000. This is in addition to benefits payable under the Dental Benefit for the
dental surgeon and anesthesia.
The hospitalization must be pre-certified by the Benefits Fund Office as described above under Pre-Certification Required.
Income Protection
Surgery often results in a period of disability during which you cannot return to work. In this situation, Income Protection
Benefits may be available to you (full-time, employee-member only). For greater details, go to the
Income Protection Benefit description or to People Often Ask About
Disability Income Protection pages of this website.
Continuation of Medical Coverage
If your doctor finds medical reasons based on objective proof that make it essential for you to stop working (total disability),
then you may be eligible under the federal Family and Medical Leave Act for up to a 12-week leave-of-absence. During the
leave-of-absence, your employer will continue to make contributions for you into the Health Fund to maintain your health
coverage.
If you remain disabled after the 12-week period or if you do not qualify for a leave-of-absence under the Family and Medical
Leave Act, you may receive an extension of your medical coverage of up to six months. To be considered for an extension,
you must immediately file a claim form, completed by you and your store
manager; also, your doctor's statement of disability must be included.
If you remain disabled at the end of the extension or if you do not qualify for an extension, you will have to make
self-payments to continue your coverage. Contact the Billing Department at the Benefits
Fund Office to find out about self-payments under COBRA to continue your coverage.
If you stop working or do not return to work while you are not totally disabled, all your coverage will terminate regardless of
any employer-approved leave of absence. Under the Federal law, COBRA, you may make
self-payments to the Plan to continue your coverage. Contact the Billing Department at the
Benefits Fund Office for details.
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