To simplify the following explanations, the term “year” means a calendar year.
The following medical benefits are provided for eligible employees and their covered dependents, and eligible retirees and their covered spouses:
- Comprehensive Benefit (for most of your medical expenses)
- Prescription Drug Program
- Wellness Benefit
- Newborn Care Benefit (Active Plan only)
These benefits are explained in the following sections.
SOME RULES GOVERNING THE PAYMENT OF MEDICAL BENEFITS
The rules listed below apply to all of the health care benefits provided by the Plan.
- All benefit payments made by the Plan are subject to the maximum benefit amounts and other limitations stated on the Schedule of Benefits.
- The Plan only pays benefits for covered expenses.
- Payments are made only for medically necessary treatment that is recommended or approved by a doctor.
- Charges are considered for payment only if they are incurred while the person who incurs them is covered under this Plan.
- You are responsible for paying, on behalf of yourself and your covered family members, the amounts of any covered medical expenses used to satisfy deductibles, the percentage the Plan does not pay, any charges that are not considered covered medical expenses, any charges that are in excess of reasonable and customary charges, and amounts in excess of any maximum benefits.
Be sure to read the exclusions and limitations in each benefit explanation section for the type of charges not covered under that benefit. In addition, the “What the Plan Does Not Cover” section includes a list of the types of expenses or types of treatment for which payment is limited or for which benefits are not payable.
If a specific item is not listed as a covered expense under any of the health care benefits explained on the following pages, or if a specific item is not listed as excluded by the Plan, determination of coverage or exclusion shall be at the sole discretion of the Trustees.
OUT-OF-NETWORK HOSPITAL DEDUCTIBLE – An out-of-network hospital is a hospital that does not participate in the Blue Cross and Blue Shield of Illinois Hospital PPO Network (BCBSIL PPO).
If a covered person is admitted to an out-of-network hospital or receives outpatient care in an out-of-network hospital, a $250 ($300 under the Retiree Comprehensive Plan) deductible will apply to the covered medical expenses incurred as a result of the hospitalization or outpatient care. A separate deductible applies to each hospitalization and each occurrence of outpatient care. Any such deductibles are in addition to the calendar year deductible.
CALENDAR YEAR DEDUCTIBLE – The first $500 ($300 under the Retiree Comprehensive Plan) of covered medical expenses incurred by a covered person during a year are used to satisfy his individual deductible. The Plan makes no payment for these expenses-you must pay them out of your own pocket before the Plan begins paying its percentage of your covered expenses.
The following rules apply to satisfying calendar year deductibles:
- Only charges considered to be covered medical expenses may be used to satisfy a calendar year deductible.
- The calendar year deductible is waived for certain types of treatment. Consult the Schedule of Benefits for details.
- Once a person has satisfied his calendar year deductible during a year, it does not have to be satisfied again during that year.
- If a person is suffering from a condition for which covered medical expenses are incurred in two or more years, the calendar year deductible must be satisfied in each year (except as noted in No. 5 below).
- The amount of the covered medical expenses incurred during October, November and/or December that are applied to a person’s calendar year deductible for that year will also apply toward satisfaction of his calendar year deductible during the next calendar year.
- Family Deductible (Active Plan) – After $1,000 has been applied to the individual calendar deductible of 3 or more covered persons in your family during a year, your family deductible will have been satisfied. The Plan will pay its 80% co-pay percentage of all covered medical expenses incurred by all of your family during the rest of that year without any further deductibles applied (except for any out-of-network hospital or prescription drug deductibles that may apply).
Plan Co-Payment Percentages
The Plan pays the following percentages of a covered person’s covered medical expenses:
SECOND SURGICAL OPINIONS – 100% (but only when recommended by Med-Care).
HEARING AIDS – 50% (Active Plan only).
ALL OTHER EXPENSES – After a covered person has satisfied his individual calendar year deductible during a year, and after satisfaction of any applicable out-of-network hospital deductibles, the Plan pays a percentage of the covered medical expenses he incurs during that year UNTIL he reaches his $2,500 out-of-pocket limit.
When a covered person’s co-payment percentage shares for most covered medical expenses (see the next paragraph), total $2,500 for a calendar year, the Plan will pay 100% of most covered medical expenses the person incurs during the remainder of that year.
AMOUNTS THAT DON’T APPLY TO OUT-OF-POCKET LIMITS – The following out-of-pocket amounts will not be used to satisfy an out-of-pocket limit:
- Calendar year and out-of-network hospital deductibles.
- Charges by out-of-network providers.
- Prescription drug co-pay percentage shares or co-pays.
- Chiropractic care expenses.
- Podiatry expenses.
- Expenses for chemical dependency treatment, or outpatient/office treatment for mental/nervous disorders.
- Speech therapy.
- TMJ treatment.
- Hospice care expenses.
- Hearing aid expenses (Active Plan only).
- Charges that are not considered covered medical expenses, or expenses incurred after any maximum benefit or limitation has been reached.
EXPENSES NOT PAID AT 100% – The Plan will not at any time pay 100% for covered medical expenses incurred for:
- Services provided by out-of-network providers.
- Chiropractic care.
- Treatment of chemical dependency or outpatient/office treatment for mental/nervous disorders.
- Speech therapy.
- TMJ treatment.
- Hospice care.
- Hearing aids (Active Plan only).
CARRY-OVER OF AMOUNTS APPLIED TO AN OUT-OF-POCKET LIMIT – If a covered person’s out-of-pocket payments during a year do not total $2,000, any out-of-pocket amounts paid for covered medical expenses incurred during October, November and/or December of that year will carry over to the next year and apply toward meeting his next year’s out-of-pocket limit.
Each covered person is entitled to benefits under the Comprehensive Benefit and for certain causes or types of treatment up to the lifetime maximum benefit or calendar year maximum benefit amounts shown on the Schedule of Benefits. The maximum benefit limitations apply whether or not there is an interruption in a person’s coverage under the Plan or if the person’s status changes; for example, if he goes from employee status to dependent status or vice versa. However, benefits paid on your (or your spouse’s) behalf under the Active Plan will not count toward the maximum benefits payable if and when your coverage starts under the Retiree Comprehensive Plan.
COMPREHENSIVE BENEFIT LIFETIME MAXIMUM BENEFIT – All benefits paid for all treatment of all injuries and sicknesses for a covered person at any time under this Comprehensive Benefit apply to the person’s Comprehensive Benefit lifetime maximum benefit. Once a person has received Comprehensive Benefits during his lifetime totaling the Comprehensive Benefit lifetime maximum benefit, no further Comprehensive Benefits will be payable for that person for the rest of his lifetime.
MAXIMUM BENEFITS FOR PARTICULAR CAUSES OR TYPES OF TREATMENT
- All benefits paid for a particular cause or type of treatment for a covered person apply to the person’s calendar year or lifetime maximum benefit for that cause or type of treatment.
- Any amount of benefits applied against any calendar year or lifetime maximum benefit for a particular cause or type of treatment will also apply to the person’s Comprehensive Benefit lifetime maximum benefit.
- Once a person has received Comprehensive Benefits for a particular cause or type of treatment during a calendar year or during his lifetime totaling the applicable calendar year or lifetime maximum benefit, no further benefits will be payable for that cause or type of treatment during the remainder of that calendar year, or during his lifetime, as applicable.
Covered Medical Expenses
Under the Comprehensive Benefit
Be sure to read the section titled “Some Rules Governing the Payment of Benefits”.
“Covered medical expenses” are the charges you and your eligible dependents actually incur for the following medically necessary services, supplies and types of treatment which are considered for payment by the Plan, subject to the maximum benefits and limitations shown on the Schedule of Benefits and subject to all limitations and exclusions which may apply.
Only allowable charges will be recognized by the Plan as covered medical expenses.
Covered medical expenses include charges incurred for the following:
- Hospital room and board if ward or semi-private accommodations are used, including general nursing services, Professional services of doctors, private duty nurses or any individual nursing care whatever it is called are excluded. If a private room is used, only the amount up to the hospital’s (or the local area’s, if the hospital has only private room accommodations) most common semi-private room rate will be a covered medical expense.
- Intensive and coronary care units, or other specialized or critical care treatment provided in a section, ward, or wing within a hospital which is operated exclusively for critically ill patients and provides special supplies, equipment, and constant supervision and care by an R.N., but not including any hospital facility maintained for the purpose of providing normal postoperative recovery, treatment or service.
- Other hospital services and supplies provided to a covered person during a hospital confinement.
- Outpatient preadmission testing – Hospital services and supplies provided for outpatient preadmission testing before a hospital admission for surgery, provided the tests:
- Are ordered by the doctor who will perform the surgery;
- Are performed in connection with the condition for which the surgery is to be performed; and
- Are medically valid at the time of the hospital admission.
- Emergency treatment – Facility services and supplies provided for emergency treatment of accidental bodily injury, whether the treatment is provided in or out of a hospital.
- Surgical facility services – Facility services and supplies provided in connection with surgery, whether the surgery is performed in or out of a hospital. The Plan excludes charges by outpatient surgical centers that are not in the BCBSIL PPO network.
- Doctors’ professional medical services, provided in or out of a hospital, including surgery, second surgical opinions and radiotherapy, as well as other medical care and treatment.
- Midwives’ services and supplies provided for prenatal care, delivery, and postnatal care to an eligible active employee, or dependent of an active employee, subject to the following:
- The midwife must be specialty-certified by the appropriate state agency; and
- If the sum of the charges made for the midwife’s services plus any necessary doctors’ services exceeds the amount of charges that would have been incurred if the entire maternity process had been handled by a doctor, covered medical expenses will be limited to the charges that would have been covered if the entire maternity process had been handled by a doctor.
- Chiropractic care up to the calendar year maximum benefit shown on the Schedule of Benefits. “Chiropractic care” means office visits, xrays, spinal adjustments and manipulations, diathermy, and other therapeutic physical therapy services that are rendered or prescribed by a chiropractor. (Chiropractic care must be precertified by Med-Care.)
- Podiatry up to the calendar year maximum benefit shown on the Schedule of Benefit. An annual maximum benefit also applies to the charges by outpatient surgical facilities. All podiatric (foot) surgery must be precertified by Med-Care. The Plan excludes charges by outpatient centers that are not in the BCBSIL PPO network.
- Reconstructive/cosmetic/elective surgery, but only as follows:
- Cosmetic surgery and/or treatment for the correction of defects incurred through traumatic injuries sustained as a result of an accident, provided the first treatment is rendered within 90 days of the date of the accident.
- Breast reconstruction following breast cancer surgery, including reconstruction of the non-affected breast to achieve a symmetrical appearance.
- Other reconstructive surgery performed in connection with or following surgery performed in connection with an injury or sickness.
- The correction of congenital defects of a child (children of active employees only).
- Vasectomies and other sterilization procedures for employees and dependent spouses.
- Physical therapy services – Professional services of a licensed physical therapist when prescribed a doctor. (Physical therapy must be precertified by Med-Care.)If the physical therapy is either prescribed by a chiropractor or provided in connection with chiropractic treatment, it is considered chiropractic care and therefore subject to the chiropractic care precertification requirement and chiropractic maximum benefit.
- Speech therapy – Professional services of a licensed speech therapist. Benefits for speech therapy for speech defects which are due to an organic cause are paid the same as for any other sickness. Benefits for speech therapy which is provided due to other than an organic cause are subject to the specific speech therapy limitations stated on the Schedule of Benefits. (Speech therapy must be precertified by Med-Care.)
- Dental treatment due to injury – Dental treatment provided by a doctor or dentist only as follows:
- Treatment of accidental injury to sound natural teeth, including the initial replacement of such teeth; and
- The setting of an accidental fracture or dislocation of the jaw, provided any such treatment is rendered within 90 days of the accident causing the injury.
- Professional ambulance service for necessary transportation of a covered person to the nearest hospital equipped to furnish treatment for the person’s injury or sickness.
- Home health care services provided by a home health agency, provided that the charges made for such services are considered covered expenses under the section entitled “Provisions Governing Home Health Care”.
- Post-cataract lenses – The first pair of contact lenses or eyeglasses required immediately after cataract surgery.
- Smoking cessation – Services and supplies provided for the purpose of smoking cessation, but only up to the maximum benefit shown on the Schedule of Benefits. Note: Pharmacy products are not covered through the Prescription Drug Program. You must file a claim withthe Fund Office.
- Obesity treatment – Services, treatments or surgical procedures provided in connection with an overweight condition or condition of obesity only if all of the following criteria are met:
- The person is 100 pounds over his medically desirable weight;
- The person has a Body Mass Index (BMI) of 45 or more;
- The obesity is a threat to the person’s life due to other complicating health factors, such as diabetes, heart trouble, hypertension, etc.;
- The person has a history of unsuccessful attempts to reduce weight by more conservative measures; and
- Before the person receives any treatment for his obesity, Med-Care must be contacted for a review of the treatment plan and must precertify that the treatment is medically necessary and meets the Plan’s criteria for coverage.
- Anesthesia and its administration.
- X-Ray and laboratory examinations made for diagnostic purposes in connection with therapeutic treatment, including radiology and pathology studies.
- Radiation therapy – X-ray, radium, and radioactive isotope therapy.
- Chemotherapy provided for cancer treatment.
- Nursing services provided by a licensed nurse, when the nursing care is prescribed a doctor.
- Hearing aids, up to the maximum benefit shown on the Schedule of Benefits.
- Hospice care in accordance with the provisions of the section titled “Provisions Governing Hospice Care”.
- Medical supplies – The following services and supplies if not covered in the above listing, provided they are prescribed a doctor for treatment, or as a result of treatment, for a covered illness or injury:
- Diabetic supplies (insulin and needles that are not covered under the Prescription Drug Program), ostomy supplies (pouches and adhesive), and tracheotomy care kits.
- Oxygen and its administration.
- Durable medical equipment – Rental of a wheelchair, hospital bed, iron lung, or other durable medical equipment for therapeutic treatment up to but not to exceed the cost of the equipment if it were purchased instead of rented. If the estimated cost for the required rental period exceeds the purchase price of the equipment, the purchase price will be considered a covered medical expense if Med-Care and the Fund Office provide authorization before the purchase. Before renting or purchasing medical equipment, Med-Care must certify that the equipment is medically necessary and is covered under the terms of the Plan.
- Breast prostheses following mastectomy. The Plan will cover up to 3 prosthetic bras per calendar year.
- Prosthetic devices for initial replacement of natural limbs or eyes.
- Surgically-implanted devices (such as pacemakers) required to aid any impaired physical organ or part of an organ in its natural body function. (Penile implants will be covered only if the impotence/disorder results from an organic cause and are limited to one implant per lifetime.)
- Blood and blood plasma and the administration of such substances.
- Casts, splints, trusses, braces and crutches.
- Orthotics – The first pair dispensed by a qualified doctor.
- Pressure stockings, up to 5 pairs per calendar year.
- Wigs when purchased due to hair loss following treatment for a covered sickness or injury, up to a maximum allowable of $250 for all wigs purchased during the person’s lifetime.
- Chair Lift to move a paraplegic or quadriplegic patient from one floor of a home to another, when the home is owned by the patient or the family member who provides daily care to the patient. The chair lift must be the most cost-effective alternative available, and cannot be solely for the patient’s or caretaker’s convenience. Precertification by Med-Care Management is required. Benefits are payable up to the maximum benefit shown on the Schedule of Benefits.
- Mental or nervous disorders – The Plan covers the same types of services and supplies listed above when a covered person is being treated for a mental or nervous disorder. Benefits are payable in accordance with the limitations specified on the Schedule of Benefits. Med-Care must be contacted for review and precertification of the treatment.
- Chemical dependency – The Plan covers the same types of services and supplies listed above when a covered person is being treated for chemical dependency. Benefits are payable in accordance with the limitations specified on the Schedule of Benefits. Med-Care must be contacted for review and precertification of the treatment plan. No benefits are payable for any part of the treatment if the course of treatment is not completed (unless the treatment is terminated for medical reasons beyond the patient’s control).
- Transplant donor expenses for an organ or tissue transplant covered by the Plan for a recipient who is eligible for benefits. Covered expenses are limited to the hospital and physician charges for removal of the organ, and necessary pre- and post-operative care. Benefits are payable up to the maximum specified on the Schedule of Benefits.
Provisions Governing Home Health Care
REQUIREMENTS – The following requirements apply to a home health care program (no benefits will be paid unless both requirements are met):
- The program of home health care treatment must be established and approved in writing by the patient’s doctor. The doctor must certify that proper treatment of the patient’s injury or sickness would require confinement in a hospital or other institution in the absence of the home health care services; and
- The care must be provided by or through an organization which meets the Plan’s definition of a home health agency.
PRECERTIFICATION BY MED-CARE – Home health care must be precertified by Med-Care if you want to get the maximum benefits possible.
If the above requirements are met but the home health care is received without obtaining precertification from Med-Care, benefits otherwise payable for the care will be reduced by 20%.
COVERED HOME HEALTH CARE EXPENSES – Covered expenses include charges made for the following services and supplies provided to a covered person in his home by or through a home health agency:
- Visits by a licensed nurse for the purpose of providing part-time or intermittent nursing care.
- Visits by a home health aide for the purpose of providing part-time or intermittent personal health care of a medical or therapeutic nature.
- Visits by a professional therapist for the purpose of providing physical, occupational or speech therapy.
HOME HEALTH CARE EXCLUSIONS
- Services which are not listed in the “Covered Home Health Care Expenses” section.
- Services provided by anyone other than an employee of the home health agency.
- Custodial care performed other than by a home health aide.
- Transportation services.
- Expenses incurred while the person is not under the continuing care of a doctor.
- Expenses incurred during any period during which confinement in a hospital or other institution would not be required if the home health care was not provided.
Provisions Governing Hospice Care
The Plan provides benefits for hospice care for persons with terminal medical conditions (life expectancy of 6 months or less).
PRECERTIFICATION BY MED-CARE – If a person wants to receive hospice care, he, his doctor, or someone acting on his behalf must contact Med-Care for precertification.
No benefits will be paid for any hospice care that is not precertified by Med-Care.
PAYMENT OF BENEFITS FOR HOSPICE CARE – Benefits for hospice care are subject to a $10,000 lifetime maximum benefit and are paid under the Comprehensive Benefit, subject to the co-payment percentages, maximum benefits, out-of-pocket limits, etc. (the calendar year deductible does not apply). However, the regular covered medical expense provisions (see “Covered Medical Expenses Under the Comprehensive Benefit”) do not apply to hospice care because hospice care includes certain types of services that are not included as regular covered medical expenses. Therefore, hospice care benefits are paid only for the special set of “covered hospice expenses” shown below.
Once a person has received $10,000 in benefits for hospice care, no further benefits for hospice care will be paid. Covered expenses incurred for any further treatment of his terminal condition will be considered for payment only under the other benefits of the Plan covering such expenses.
Charges incurred for treatment of a person’s terminal condition other than those listed as Covered hospice expenses are not considered for payment as hospice care expenses. Such expenses include charges for long-term inpatient care, surgical operations or hospital confinements due to medical complications of the terminal condition, etc. In addition, charges incurred for treatment of any injury or sickness other than the person’s terminal condition are not considered for payment as hospice care expenses. (Covered expenses incurred for such treatment will be considered for payment under the other benefits of the Plan covering such expenses.)
COVERED HOSPICE EXPENSES – Covered hospice expenses are charges made for the following services and supplies provided by a hospice or provided through arrangements made by a hospice for care of a terminally ill person:
- Nursing care by an R.N. or L.P.N. and services of homemakers and home health aides (these services may be furnished on a 24-hour basis during a period of crisis or if the care is necessary to maintain the patient at home).
- Medical social services provided under a doctor’s direction.
- Counseling services and/or psychological therapy rendered by a social worker or a psychologist.
- Physical and occupational therapy and speech language pathology.
- Non-prescription drugs used for palliative care; medical supplies, bandages and equipment; and drugs and biologicals used for pain and symptom control.
- Skilled nursing facility short-term inpatient care to provide respite care, palliative care, or care in periods of crisis.
Benefits will be payable for the above covered hospice expenses even if they are normally excluded from coverage under the Plan-for example, services of social workers and non-prescription medications.
HOSPICE CARE EXCLUSIONS
- Services or supplies not provided as “core services” by the hospice providing the care; or charges made for services or supplies that are not listed as covered hospice expenses.
- Bereavement counseling provided to a terminal person’s family after the patient’s death.
- Administrative services, child care and/or housekeeping services, or transportation (except in emergency situations).
- Services or supplies that are rendered, provided or supplied by family members.
Comprehensive Benefit Exclusions And Limitations
- Any of the services or supplies listed under the “Home Health Care Exclusions” or “Hospice Care Exclusions” sections.
- Any services, supplies or types of treatment for which no benefits are payable under the Plan as a whole as stated in the “What the Plan Does Not Cover” section.
- Charges incurred in excess of any maximum benefit or other limitation stated on the Schedule of Benefits.
- Prescription drugs.Exception: Expenses incurred for prescription drugs obtained from a pharmacy that does not participate in the Drug Card Program may be considered covered medical expenses if there is no participating pharmacy located in your mailing zip code area; or if the prescription was filled at a non-participating pharmacy that is located more than 100 miles from your home.
This benefit provides coverage for a wide range of routine and preventive health services for you, your spouse, and, if you are an eligible active employee, your children. Covered expenses include routine physical examinations, routine x-ray and laboratory tests and preventive immunizations.
PAYMENT OF BENEFITS – Each calendar year the Plan will pay up to the following amounts for covered expenses incurred for routine physical examinations and routine and preventive services:
- $300 for employees, retirees, spouses and children under age 6.
- $100 for children age 6 through 22.
The Plan will pay 100% up to these maximum, and no deductible will apply. The Plan will also pay 100% for routine childhood immunizations received from birth through age 5. These benefits will not apply to the child’s $300 Wellness Benefit maximum.
This is the only benefit that covers routine and preventive services. Expenses incurred by a person in excess of the maximum specified above during a year do not carry over for payment under the Comprehensive Benefit. Charges in excess of the maximum per year are your responsibility.
COVERED WELLNESS EXPENSES
- Doctors’ services and supplies.
- X-ray and lab tests, including Pap smears and mammograms for females, and PSA tests for males.
- Immunizations, inoculations, flu shots, etc.
- Any other diagnostic tests or procedures ordered by the examining doctor.
WELLNESS BENEFIT EXCLUSIONS
- Expenses in excess of the scheduled maximum benefit (does not apply to childhood immunizations).
- Any examination or service provided for nonroutine purposes.
- Any treatment of a condition diagnosed as a result of a routine examination.A routine physical examination is an examination a doctor performs to see if a person has any health problems when there are no symptoms. If a person goes to a doctor for an exam when he has symptoms of a health problem, that exam is not considered “routine” and the covered expenses incurred for the exam are not paid under this benefit. They are considered for payment under the Comprehensive Benefit, subject to the Comprehensive Benefit’s deductibles, copay percentages, out-of-pocket limits and maximum benefits. The same applies if a person goes to a doctor for a routine examination and, as a result of the examination, a condition that requires treatment is diagnosed.
NEWBORN CARE BENEFIT
(Children of Active Employees Only)
Payments are made under this benefit for hospital and physician expenses incurred for routine newborn care and for a healthy newborn dependent child during the child’s first seven (7) days after birth. Benefits are payable at 100% of the incurred covered expenses up to a maximum benefit of $2,500. No deductible applies to these expenses.
(If a newborn child is premature, injured, sick, etc., no benefits are paid under this benefit. Instead, expenses incurred for the child’s treatment are considered for payment under the Comprehensive Benefit.)