Medical Benefits

Comprehensive Medical Benefit

To simplify the following explanations, the term “year” means a calendar year.

OVERVIEW

The rules listed below apply to all of the health care benefits provided by the Plan.

1. All benefit payments made by the Plan are subject to the maximum benefit amounts and other limitations stated on the Schedule of Benefits.
2. The Plan only pays benefits for covered expenses.
3. Except for covered preventive services, payments are made only for medically necessary treatment that is recommended or approved by a doctor.
4. Charges are considered for payment only if they are incurred while the person who incurs them is covered under this Plan.
5. In determining the satisfaction of any deductible amounts and the amount of benefit payments, a charge for any service or supply is considered to have been incurred on the date the service was rendered or on the date the supply was provided.
6. 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, penalties, the percentage the Plan does not pay, any charges that are not considered covered medical expenses, any charges that are in excess of allowable 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.

CALENDAR YEAR DEDUCTIBLE

The first $500 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:

1. Only charges considered to be covered medical expenses may be used to satisfy a calendar year deductible.
2. The calendar year deductible is waived for certain types of treatment. Consult your Schedule of Benefits for details.
3. Once a person has satisfied his calendar year deductible during a year, it does not have to be satisfied again during that year.
4. 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).
5. 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.
6. Family Deductible (Active Plan) – After $1,000 has been applied to the individual calendar deductibles of two 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 covered family members during the rest of that year without any further deductibles applied.

PLAN CO-PAYMENT PERCENTAGES

The Plan pays the following percentages of a covered person’s covered medical expenses:

PREVENTIVE – 100% for the in-network services and supplies shown in the list that starts on the Active Schedule of Benefits. (Out-of-network services are subject to coinsurance and paid up to the allowable charge.)

SECOND SURGICAL OPINIONS – 100% (but only when recommended by Med-Care).

HEARING AIDS – 50% (Active Plan only) up to $3,000 in a two-calendar year period.

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 penalties, the Plan pays 80% of the allowable charge for covered medical expenses he incurs during that year UNTIL he reaches his $2,500 out-of-pocket limit.

OUT-OF-NETWORK HOSPITAL PENALTY – 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 non-surgical outpatient care in an out-of-network hospital, a $250 penalty applies ($300 under the Retiree Plan). The penalty amount is deducted from the covered medical expenses that would otherwise be paid at 80%, and you will be responsible for paying that amount to the hospital. A separate penalty applies to each hospitalization and each occurrence of outpatient care. Some exceptions to the application of this penalty are described here.
 
Note that out-of-network surgical facilities are not covered by the Plan.

OUT-OF-POCKET LIMIT

When a covered person’s deductible and co-payment percentage shares for most covered medical expenses, total $2,500 for a calendar year, the Plan will pay 100% of most in-network covered medical expenses the person incurs during the remainder of that year.
 
The Active Plan also has a family out-of-pocket lim-it. Once two or more covered members of your family accumulate a total of $5,000 in expenses ap-plied toward their individual out-of-pocket limits for a calendar year, the out-of-pocket limits for all your covered family members will be considered met for 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:

• Charges by out-of-network providers. There are two exceptions to this rule:
  1. Out-of-network emergency room charges for a true emergency; and
  2. Out-of-network charges that have been negotiated by Med-Care or another organization acting on the Fund’s behalf;
• Out-of-network hospital penalties;
• Prescription drug co-pays (a separate out-of-pocket limit applies to prescription drugs); or
• Charges that are not considered covered medical expenses, or expenses incurred after any maxi-mum benefit or limitation has been reached.

Out-of-network expenses will not be paid at 100% even if your out-of-pocket limit has been met.
 

COVERED MEDICAL EXPENSES

Unless otherwise specified, the following medical expenses are covered subject to the deductible, coinsurance and other limitations shown on your Schedule of Benefits.
 
Only allowable charges will be recognized by the Plan as covered medical expenses. In addition, the Plan will only cover medically necessary treatment and supplies, unless an exception is specifically stated (such as for preventive care).

Covered medical expenses include charges incurred for the following:
 

1. Applied Behavior Analysis (ABA) therapy or similar behavioral modification programs when provided by a licensed therapist. ABA therapy must be pre-certified by Med-Care.
2. Acupuncture – Up to 12 acupuncture sessions per calendar year when performed by a medical doctor, chiropractor, or licensed acupuncturist. The treatment must be prescribed by a medical doctor or chiropractor. Acupuncture must be pre-certified by Med-Care.
3. Ambulance service for necessary transportation of a covered person to the nearest hospital equipped to furnish treatment for the person’s injury or sickness.
4. Anesthesia and its administration.
5. Aqua Therapy (hydrotherapy) when prescribed by a physician for a specific medical condition and performed by a licensed physical therapist or physical therapy assistant. Must be pre-certified by Med-Care.
6. Chiropractic care up to the calendar year maximum benefit shown on the Schedule of Benefits. “Chiropractic care” means spinal manipulations and/or adjustments, and all related therapies, except physical therapy, massage therapy and acupuncture, which have separate maximums and limitations. Chiropractic care must be pre-certified by Med-Care.
7. Clinical trials – The routine patient costs for a covered person enrolled in an approved clinical trial. While the Plan may require you to use an in-network provider participating in a clinical trial if the provider will accept you as a participant, the Plan will cover routine non-network patient costs for covered persons enrolled in a clinical trial outside of the person’s state of residence. An “approved clinical trial” is defined as a Phase I, II, III or IV clinical trial for the prevention, detection or treatment of cancer or other life-threatening condition that is: (a) federally funded or ap-proved; (b) conducted under an investigational new drug application reviewed by the Food and Drug Administration; or (c) a drug trial that is exempt from having such an investigational new drug application. A “life-threatening condition” is any disease from which the likelihood of death is probable unless the course of the disease is interrupted. “Routine patient costs” include all services and supplies that are typically covered by the Plans for persons not enrolled in clinical trials. Routine patient costs do NOT include: (a) the investigational item, device, or service itself; (b) services that are provided solely to satisfy data collection and analysis needs; or (c) services that are clearly inconsistent with the widely accepted and established stand-ards of care.
8. Dental treatment – The following dental treatment is covered under the medical plan when provided by a doctor or dentist:
   • Treatment of accidental injury to sound natural teeth, including the initial replacement of such teeth;
   • Surgical removal of bony impacted teeth;
   • The setting of an accidental fracture or dislo-cation of the jaw, provided any such treat-ment is rendered within 90 days of the acci-dent causing the injury; and
   • Oral appliances prescribed by a doctor but provided by a dentist for the treatment of sleep apnea.
9. Durable medical equipment – Rental of a wheel-chair, hospital bed 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 covered under the terms of the Plan.
10. Emergency facilities – Hospital and urgent care facility services and supplies provided for emergency treatment of accidental bodily injury, whether the treatment is provided in or out of a hospital.
11. FDA-approved home kits that screen for cancer cells in the patient’s stool (such as Cologuard®) for participants aged 50 or over who have a physician’s prescription.
12. Hearing aids, up to the maximum benefit shown on the Schedule of Benefits. For the purpose of Plan benefits, “hearing aid” means a wearable device designed for the ear. It does not include amplifiers or other assistive listening devices such as FM systems.
13. Home health care services provided by a covered home health agency as follows:
    • 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; and
    • Visits by a professional therapist for the purpose of providing physical, occupational or speech therapy.

    The home health care must be prescribed by doctor and be in lieu of inpatient confinement. Transportation services and custodial services are not covered. All home health care must be pre-certified by Med-Care.
     

14. Hospice care provided by a hospital or licensed hospice agency to a terminally ill patient, as follows:
    • Nursing care;
    • Home health aides;
    • Medical social services;
    • Counseling services and/or psychological therapy rendered by a social worker or a psy-chologist, including chaplaincy;
    • Physical, occupational therapy and speech therapy;
    • Non-prescription drugs used for palliative care; medical supplies, bandages, and equipment; and drugs and biologicals used for pain and symptom control; and
    • Skilled nursing facility short-term inpatient care to provide respite care, palliative care, or care in periods of crisis.

    Hospice care must be pre-certified by Med-Care.
     

15. Hospital services and supplies, including:
    • Hospital room and board, including intensive and coronary care units, or other specialized or critical care treatment;
    • Ancillary services, including operating room services, tests, and medical supplies;
    • Outpatient services, including outpatient sur-gical services at a hospital or outpatient surgical facility (except that out-of-network sur-gical facilities are excluded);
    • Emergency room services when the condition being treated is an emergency); and
    • C-Pap Machine.

    Hospitalizations must be pre-certified by Med-Care.
     

16. Medical supplies and devices – The following services and supplies when prescribed by 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 and one pair of diabetic shoes per year up to $250), ostomy supplies (pouches and adhesive), and tracheotomy care kits;
    • Oxygen and its administration*;
    • Surgically implanted devices* (such as pace-makers) 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 life-time;
    • Blood and blood plasma and the administration of such substances*;
    • Casts, splints, trusses, braces and crutches;
    • Foot orthotics and one pair of orthopedic shoes for children under one-year of age*;
    • Pressure stockings, up to five 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 $300 every five calendar years; and
    • 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. Benefits are payable up to the maximum benefit shown on the Schedule of Benefits.

    * Precertification by Med-Care is required.
     

17. Massage therapy – Up to 12 massage therapy sessions per calendar year when performed by a medical doctor, chiropractor, or licensed massage therapist. The therapy must be medically necessary and prescribed by a medical doctor or chiropractor. Massage therapy will only be covered when it is accompanied by other physical therapy modalities. Massage therapy must be pre-certified by Med-Care.
18. Mental or nervous disorders – Inpatient treatment at a hospital or residential treatment facility, and outpatient treatment by a doctor, psychologist or licensed professional counselor. Inpatient care must be pre-certified by Med-Care.
19. Midwives’ services for prenatal care, delivery, and postnatal care, 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 mid-wife’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.
       
20. Nursing services by a licensed nurse when prescribed a doctor.
21. Nutritional counseling prescribed by a physician (M.D. or D.O.) for medical conditions for which dietary adjustments are therapeutic and appropriate. The services must be provided by a licensed nutritionist, registered dietician, or nurse.
22. Obesity treatment – Services, treatments or sur-gical procedures provided in connection with an overweight condition or condition of obesity, but only if all of the following criteria are met:
    • The person has a body mass index (BMI) of 40 or higher, or a BMI of 35 to 39.9 with at least one serious weight-related health problem such as diabetes or hypertension;
    • The obesity is a threat to the person’s life due to life-threatening co-morbidities such as diabetes, hypertension, heart disease, etc.;
    • The person has a documented history of unsuccessful weight loss attempts; and
    • The person is between the ages of 18 and 65.
       
23. Occupational therapy prescribed by a doctor and rendered by a licensed occupational therapist or licensed occupational therapy assistant. The therapy must be pre-certified by Med-Care.
24. Physical therapy services up to the limitation shown on the Schedule of Benefits. The therapy must be prescribed by a doctor and rendered by a licensed physical therapist, physical therapy assistant or chiropractor. Physical therapy must be pre-certified by Med-Care.
25. Podiatry – Non-surgical podiatry is covered up to the calendar year maximum benefit shown on the Schedule of Benefit. The maximum does not apply to treatment of a metabolic or peripheral vascular disease. Surgical podiatry is covered if it is pre-certified by Med-Care. Reminder: The Plan excludes charges by outpatient surgical facilities that are not in the BCBSIL PPO network.
26. Post-cataract lenses – The first pair of contact lenses or eyeglasses required immediately after cataract surgery.
27. Pregnancy care, including necessary prenatal and postnatal care. Abortions are also covered.
28. Preventive services as described in the “Preventive Benefits”
29. Professional medical services provided in or out of a hospital for surgery, second surgical opinions, anesthesiology, radiology, pathology, and other medical care and treatment. Services must be rendered by a licensed, qualified medical professional acting within the scope of his or her license and specialty. The Plan covers professional services by the following types of licensed (if licensing is required pursuant to applicable state or local law) medical practitioners, but only if the service they are providing is covered by the Plan:
    • Acupuncturist
    • Aqua therapy
    • Behavioral therapist
    • Chiropractor
    • Dentist and oral surgeon
    • Home health care agency
    • Hospice agency
    • Nutritionist
    • Massage therapist
    • Medical doctor (M.D. or D.O.)
    • Mental health/substance abuse practitioner with Master’s degree
    • Medical supply/durable medical equipment supplier
    • Midwife
    • Nurse, including registered nurse, licensed practical nurse, and advanced practice nurse
    • Occupational therapist or occupational therapy assistant
    • Optometrist
    • Physical therapist or physical therapy assistant
    • Physician’s assistant
    • Podiatrist
    • Psychologist
    • Speech or speech-language therapist

     
    The Trustees may, at their discretion, cover services by other licensed providers if they determine that the other provider has comparable training and certification to the providers listed above, and that the service being provided is within the scope of the unlisted provider’s license and clinical training.
     
    Note: The Plan excludes treatment that is not the normal standard of care, including but not limited to alternative, complimentary and non-standard treatments.

30. Prosthetic devices for initial replacement of natural limbs or eyes, including breast prostheses following mastectomy and up to three prosthetic bras per calendar year.
31. Radiation therapy and chemotherapy
32. Reconstructive surgery, but only as follows:
    • For correction of congenital defects of a child (children of active employees only);
    • 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; and
    • Other reconstructive surgery performed in connection with or following surgery performed in connection with an injury or sickness.
       
33. Skilled nursing facility confinements when pre-certified by Med-Care.
34. Sleep studies, when medically necessary, or when required as part of a Department of Transportation physical for an active employee. Sleep studies must be pre-certified by Med-Care.
35. Speech therapy by a licensed speech therapist to restore speech lost due to an accident or injury. Habilitative speech therapy is subject to the imitations stated on the Schedule of Benefits. Habilitative speech therapy is not covered if it is educational or for a non-pervasive developmental delay. Speech therapy must be pre-certified by Med-Care.
36. Substance abuse treatment* – Inpatient, intensive outpatient and regular outpatient treatment provided by a hospital, a substance abuse treatment facility, an M.D. or a licensed professional counselor. Inpatient and residential care must be pre-certified by Med-Care.
37. Surgical facilities – 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 facilities that are not in the BCBSIL PPO network.
     
    Surgery must be pre-certified by Med-Care.
     
38. 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. Precertification by Med-Care is required.
39. Medical expenses incurred while the participant is traveling abroad up to $250 per participant per occurrence.
40. Urgent treatment at a licensed urgent care facility.
41. Voluntary sterilization procedures (for employees and spouses only) such as vasectomies and tubal ligations.
42. X-Ray and laboratory examinations made for diagnostic purposes in connection with therapeutic treatment, including radiology and pathology studies.

PREVENTIVE CARE BENEFITS

The Plan covers a wide range of preventive services designed to keep participants and dependents healthy. Benefits for the preventive services will be paid as follows:

• 100% with no deductible when you use an in-network (Blue Cross Blue Shield PPO) provider.
• 80% for out-of-network (non-PPO) services. If there is no available network provider, the 100% level will be paid for out-of-network services (up to the allowable charge).
• Covered immunizations can also be obtained at a participating Sav-Rx pharmacy at no cost to you, and with no claims to file, if you show the pharmacist your Sav-Rx card.
• You can also use your Sav-Rx card to obtain the pharmacy products covered under this benefit, including products covered at 100% with no deductible.

 
The services covered under this benefit are based on the following recommendations and are subject to change:

• United States Preventive Services Task Force (services/items with a rating of A or B);
• Immunizations recommendation from the Advisory Committee on Immunization Practices and adopted by the Centers for Disease Control and Prevention; and
• With respect to infants, children, adolescents and women, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

 
The list of covered services and supplies is listed below. This list is subject to change based on determinations made by the federal agencies responsible for these recommendations.