Eligible Medical Expenses

Benefits are payable for the Reasonable and Customary charges incurred for treatment, services and supplies ordered by a Physician for care and treatment of an injury or illness covered under the Plan.  The level of reimbursement depends on if you utilize In-Network or Out-of-Network providers (refer to the Schedule of Benefits).  Eligible medical expenses are as follows:

Ambulance Service

• Charges for a licensed professional ambulance service for transportation to or from a hospital.

Pre-Admission Testing

• Charges for tests required before a hospital admission performed in a physician’s office or outpatient facility.

Hospital

• Inpatient Hospital charges for the first one hundred and eighty (180) days for inpatient treatment per confinement.  Covered room and board charges may not exceed the hospital’s average rate for semi-private rooms.  If a private room is used, covered room and board charges may not exceed the Hospital’s average rate for semi-private rooms.  If a hospital does not have semi-private rooms, the coverage charges may not exceed the average rate for such rooms charged by the hospitals located in the surrounding geographical area.
• Critical Care Units (CCU) and Intensive Care Units (ICU)
• Pre-Admission tests required before a hospital admission
• Routine nursery care or maternity care of a newborn child during the mother’s inpatient hospital stay
• Staff physician visits and treatment of a medical condition and inpatient nursing services by a registered graduate nurse (RN)
• Services provided by anesthesiologists, pathologists, radiologists, surgeons and other physicians who visit or treat you while in the hospital
• Charges for blood and blood plasma, and the administration thereof
• Prescribed drugs, medications, intravenous injections and solutions
• Any miscellaneous charges which are customarily provided to treat a medical condition that resulted in the hospitalization
• Charges by a Hospital for outpatient treatment
• Charges by a Hospital or licensed rehabilitation facility for treatment of alcoholism or drug addiction upon the recommendation and approval of a licensed Physician

Emergency and Urgent Care

The Plan provides coverage for emergency and urgent care services provided in a physician office, hospital emergency room or urgent care facility.

Preventive Care

Benefits for preventive care, as detailed below, will be paid at 100%, then 50% thereafter per covered individual, without application of the calendar year deductible.  Covered services include:

• Mammogram, limited to one exam per calendar year
• Pap smear and related office visit, limited to one such exam per calendar year
• HPV testing and vaccination, limited to one exam per calendar year
• Immunizations, including vaccines and flu shots
• Routine physical exam, limited to one exam per calendar year
• Prostate exam, limited to one exam per calendar year
• Colonoscopy exam for screening purposes, limited to:

• One exam every ten (10) years, if under age fifty (50)

• One exam every five (5) years, if age fifty (50) and over

Benefits will not be provided under this Preventive Care Benefit for treatment, including diagnostic testing, of any illness or injury.  Charges for treatment of an illness or injury will be considered under the Comprehensive Major Medical Benefit as detailed in this booklet.

Laboratory Benefit

The Plan will pay 100% of covered charges submitted by a free-standing Blue Cross Blue Shield network laboratory facility for outpatient laboratory testing, without application of a calendar year deductible.  This benefit will not apply to laboratory charges submitted by a hospital, whether the patient is confined or not confined.

Charges submitted by an out-of-network provider will be covered at 70% and subject to the calendar year deductible.

Should Medicare be your primary insurance, or should you be a dependent with another primary insurance carrier, your LabOne claim will need to be processed by Medicare, or your primary insurance carrier, before this Plan can process your claim and coordinate benefits.

Office Visits

The Plan provides coverage for office visits to a physician and specialist and for surgery performed in the physician’s office.  Typical types of charges included:

• Physician and specialist charges for diagnosis, treatment and surgery
• Charges related to providing a second opinion
• Drugs and medicine which, by law, require a Physician’s written prescription
• Services by a physiotherapist under the supervision of a Physician

Surgery

• Surgical procedures performed on both an inpatient and outpatient basis
• Cosmetic surgery required by an accidental bodily injury which occurred while covered by the Plan

• Reconstructive surgery due to a congenital disease or anomaly of a dependent child which has resulted in a functional defect
• Gastric By-Pass or Gastric Banding up to a maximum of $25,000
• Mastectomy, including:

• Reconstruction of the breast on which the mastectomy has been performed

• Surgery and reconstruction of either or both breasts to produce a symmetrical appearance

• Prostheses and treatment of physical complications in all stages of mastectomy, including lymph edemas

Should your physician recommend an elective surgery, the Plan also provides coverage for a second opinion.

Facility Fees

The Plan provides coverage for surgical or outpatient procedures and treatments performed at a free-standing facility.

Mental Nervous

Charges for Day Treatment Program expenses for the outpatient treatment of substance abuse and psychiatric counseling, including pain management, provided the day treatment care meets all of the following requirements:

• Follows an inpatient confinement of at least three (3) days;
• Commences within three (3) days of the hospital discharge;
• Is recommended by a physician; and
• Is rendered by a provider licensed for such treatment by the state of domicile.

Oral/Vision Care Benefit

If while covered, you or an eligible dependent incur expenses for dental services which are not covered under the Major Medical Benefit, such expenses will be reimbursed at 100%.  The maximum benefit which will be paid on behalf of any covered individual is $500 for expenses incurred in a calendar year.

In regards to pediatric oral/vision care, if an eligible minor child(ren), age 19 or less, incurs expenses for oral or vision care services which are not covered under the Major Medical Benefit, such expenses will be reimbursed at 100% of the first $500, then 50% thereafter.

Please note, Orthodontics are not considered as an "essential health benefit", and are not covered under the Oral Care Benefit.

This benefit is intended to be a reimbursement arrangement where you pay the service provider’s bill and submit a receipt to the Fund Office for reimbursement.  If you and the service provider can reach an agreement where the service provider will accept payment from the Fund, with you responsible for the difference, you can instruct the service provider to submit his bill directly to the Fund Office and the Fund’s check will be made payable to the service provider.

Dental Work or Treatment 

The Plan provides coverage for dental work, surgery or treatment required to repair, replace, restore or reposition sound natural teeth or other body tissues as a result of an injury that occurred while the patient was covered under the Plan.  Coverage is also provided for:

• Charges for the treatment of a cleft lip or palate;
• Charges for the treatment of temporomandibular joint disease (TMJ), including office visits and bite splints; excluding orthodontic treatment and retainers;
• Charges for the treatment of cysts or tumors; and
• Charges for the treatment of cancer of the jaw or mouth.

Eye Care or Treatment

The Plan provides coverage for the treatment of glaucoma and cataracts, and also for charges related to an accidental eye injury occurring while eligible for benefits.  The Comprehensive Major Medical Plan does not provide coverage for routine eye refractions, eyeglasses, contact lenses or charges for eye surgery or treatment primarily to correct refractions.

Chiropractic Care

The Plan provides coverage for chiropractic care provided by a chiropractor, limited to either a maximum of twenty (20) visits per calendar year or a total of $1,000, whichever occurs first.  Charges for x-rays are included in this benefit.

Physical Therapy and Speech Therapy

The Plan provides coverage for physical therapy, limited to a maximum of twenty (20) visits per condition per calendar year.  The therapy must be medically necessary and not for developmental or educational purposes.

Charges related to speech therapy must be medically necessary, require a treatment plan and may initially be approved for twenty-four (24) visits.  Additional visits may be permitted after the review of therapist’s documentation and progression.  Speech therapy is limited to a maximum of forty-eight (48) visits.

Maternity Care 

The Plan provides coverage for physician charges for all obstetrical care, including the initial visit and all prenatal and postnatal visits, and delivery in a hospital or birthing center.  Newborn benefits include the hospital’s nursery charges incurred during the mother’s confinement. 

Also covered are services rendered by a birthing center (as defined by State Law) including any charges for care rendered by a licensed nurse-midwife (or by a midwife as defined by State Law) providing services within the scope of his license as permitted by State Law.

You must enroll a newborn within thirty (30) days after birth in order for the Plan to identify the dependent on future claims.

Premature Birth and Congenital Malformation

Medical expenses incurred while you are covered with respect to a dependent child for treatment of a child’s premature birth or congenital malformation will be considered for benefits as though such expenses were due to a disease of the child.  Premature birth will be deemed to have occurred only if a doctor certifies to such prematurity and the child requires confinement in an incubator or the premature baby room of a hospital.

Abortions

The Plan covers both elective and therapeutic procedures for participants and covered dependents.

Weekly Disability Benefits

The Plan provides coverage should you become totally disabled due to a non-occupational accidental bodily injury or disease.  Benefits will begin on the day of disability following the applicable waiting period specified in the Schedule of Benefits and will continue during the continuance of total disability for up to twenty-six (26) weeks.  The amount of the benefit is shown in the Schedule of Benefits.

If while covered, you become totally disabled due to pregnancy, you will be eligible for this benefit, subject to the same provisions regarding commencement and duration of benefits as would be applicable to any disease.

Successive periods of disability separated by less than two (2) weeks of continuous full-time active work shall be considered as one period in determining the benefits available to you, unless the subsequent disability is due to an injury or disease entirely unrelated to the cause of the previous disability and commences after your return to full-time active work.

This benefit will not be payable for a disability due to injury or disease for which you are not under regular treatment by a physician.

Skilled Nursing Facility

A Skilled Nursing Facility provides for a level of services that are often essential after a hospital stay, such as rehabilitation, physical, speech, or occupational therapy.  The Plan provides coverage for room and board charges and requires the attending physician to certify the admission to the facility is medically necessary as a substitute for hospital confinement.  Skilled nursing is limited to coverage for up to sixty (60) days and must be for patient rehabilitation.  A Skilled Nursing Facility must meet the following requirements:

• Licensed physician on call 24 hours a day;
• Registered Nurse (RN) on duty 24 hours a day;
• Each patient must be under the care of a physician; and
• Skilled Nursing Facility must be licensed by the State

The Plan does not provide coverage for charges related to a convalescent nursing home, rest facility or facility for the aged that furnishes primarily Custodial Care, including training in routines of daily living.

Home Health Care

Home Health Care is generally for the treatment of an illness or injury in the patient's home and begins immediately following an inpatient hospital stay.  The Plan provides coverage only for medically necessary services and supplies which are rendered to a patient at home by a licensed agency or individual, excluding a family member or resident of the household.  No coverage is provided for custodial care, housekeeping services, child care, cooking, bathing or laundry services.  Home Health Care coverage must meet the following requirements:

• Condition calls for intermittent (part-time) Registered Nurse (RN) care, physical, speech, or occupational therapy;
• Individual is confined to the home; and
• A physician determines home health care is needed and sets up the home health care plan

Hospice Care

Hospice is a public agency or private organization that is primarily engaged in providing pain relief, symptom management, and support services to terminally ill patients and their families.  The Plan provides coverage for the following:

• Outpatient medical and support services from an approved Hospice
• Outpatient nursing care provided by a Registered Nurse (RN)
• Physical or occupational therapy or speech language pathology

The Plan does not provide coverage for Hospice charges for an inpatient hospital environment.

Diabetic Services and Supplies

The Plan provides coverage for services and supplies related to the care and treatment of diabetes.  Coverage is also provided for glucometers, blood glucose monitors and infusion devices, including charges for insulin needles and syringes, visual reading strips, urine test strips and injection aids such as lancets and alcohol swabs.

No coverage is provided for outpatient educational or training charges by a certified nutritionist or licensed dietitian.

Durable Medical Equipment

The Plan provides for monthly rental to the purchase price of durable medical equipment (DME) when prescribed by a physician.  Charges for repair are covered due to reasonable wear and tear usage.  Replacement costs are covered only if the durable medical equipment is unable to be repaired or due to the patient’s growth or anatomical changes.

Durable medical equipment must be medically necessary and some equipment requires specific criteria to be met before being approved for coverage.  Typical types of durable medical equipment are as follows:

• Wheelchairs
• Hospital type beds
• Iron lungs
• Dialysis machines
• Kangaroo Pumps
• Nebulizers
• Oxygen concentrators
• C-Pap or Bi-Pap            (for moderate to severe sleep apnea)

The Plan provides coverage for the supplies required for the administration of covered durable medical equipment.

No benefits are payable for items which are not medically necessary and are considered as convenience items.  Typical types of equipment which are ineligible expenses include, but are not limited to:

• Air purifiers, humidifiers and vaporizers
• Bed related items such as mattresses, pillows and tables
• Bath related items such as grab bars, rails, raised toilet seats and bath benches
• Heat lamps, sun lamps, heating pads or any form of ultraviolet beds or cabinets
• Pools or spas for aqua therapy

Orthotics

The Plan provides coverage for orthotic devices which are medically necessary to support or aid in the treatment of an injury or illness and prescribed by a physician.  Coverage is also provided for all medically necessary supplies, adjustments, repairs or replacement of covered orthotic devices.  Replacement of orthotics is generally provided following a malfunction of the device, for growth adjustments, or after the device’s normal life span.  Typical types of orthotics are:

• Splints and Trusses
• Braces for the arm, back, leg, neck or shoulder
• Custom molded foot orthotics

The Plan provides coverage for foot orthotics if they are custom molded from a mold of the patient’s foot and prescribed by a physician.  Orthopedic shoes are not eligible for coverage unless one or both of the shoes are an integral part of a leg brace.

Over the counter support devices are not eligible for coverage.

Prosthetics

The Plan provides coverage for prosthetic devices such as artificial limbs or eyes, which are prescribed by a physician as a replacement of a natural limb or eye lost while a covered individual and must be medically necessary for the correction of an injury, illness or congenital defect.

The Plan provides coverage for the initial purchase and fitting of the device.  Coverage is also provided for repairs and replacements which are due to reasonable wear and tear or anatomical changes that are not otherwise provided under the manufacturer’s warranty or purchase agreement.  No coverage is provided for repairs or replacements that are the result of a covered individual’s misuse.

A prosthetic device requires a Letter of Medical Necessity from the physician.  Typical types of prosthetics are as follows:

• Basic limb prosthetic
• Eye prosthetic
• Breast prosthetic
• Penile prosthetic
• Bra
• Wig