C o n n e c t i c u t C a r p e n t e r s H e a l t h F u n d P
l a n
Medical Benefits – Full Plan
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You and your dependents need affordable, quality health
care. The Health Fund’s goal is to help you obtain it — with coverage that
ranges from preventive examinations and tests to organ transplants. The
benefits you’re offered may change from time to time. You will always be
given full information from the Health Fund about the medical plan that
covers you. Through the Connecticut Coalition of Taft-Hartley Health
Funds, the Health Fund has an arrangement with a Preferred Provider
Organization (PPO), which consists of a network of hospitals, doctors and
other providers who agree to accept discounted fees for covered services.
Consult your provider directory — distributed by the Health Fund Office at
not charge — or call the PPO toll free to find out if the providers you want
to see participate in the PPO. Under the plan, you may go to the provider of your choice.
If you go to a provider in the PPO network, you may pay less out-of-pocket
for your share of the cost. If you go to a provider outside the network (a
non-network provider), you won’t have a penalty. But you may have to file a
claim form and get reimbursed for your portion of the cost of care. If
you’re considering a procedure or treatment and you’re not sure if it’s
covered, call the Health Fund Office toll-free at 1.800.922.6026 to find out. If
you become covered for the first time or have your coverage reinstated after
an absence of a year or more and you received treatment for any sickness or
injury in the six months before you became covered, that injury or illness is
considered a pre-existing condition and won’t be covered under the Health
Fund for the first 12 months of coverage. The
Health Fund will use your creditable coverage under another group health plan
to reduce the 12-month pre-existing condition limitation period. Lifetime
Maximum The
Health Fund limits the amount of benefits it will pay under the Full Plan to
$1,000,000 per person, per lifetime. The
limit covers all benefits paid to you from the Full Plan, both while you’re
working and retired. The maximum applies to all benefits except prescription
drugs obtained through the prescription drug benefit, vision care, death and
Accidental Death & Dismemberment (AD&D) benefits. |
Medical Benefits
Full Plan
Full Spectrum
Full Health
Medical/Drug Only
Disabled Member
Retiree Full |
What You Pay For
Deductible
Before
the Health Fund pays for your covered medical expenses, you pay for your
medical care up to a certain dollar amount — the annual deductible.
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The
Individual Deductible is $250.
·
The
Family Deductible is $500 —you need to meet the deductible amount for only two
members of your family.
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The
Common Accident Deductible is $250 — you need to meet only one deductible
amount when your family is involved in the same accident.
Copay
The
copay is a set dollar amount you pay when you go to a doctor in the network. If
you go to a non-network doctor, you are still responsible for $10 that would
have been your copay to a doctor in the network. The Health Fund pays 100% of
the remaining allowable charges of the office visit only. Allowable charges are
based on reasonable and customary — R&C — charges, which are calculated on
the average amount being charged for medical services in Connecticut, or the
PPO contracted rate. There is no copay if you’re covered under a retiree plan
and Medicare is your primary coverage.
Coinsurance
After
you’ve met the deductible, you and the Health Fund share the cost of your
medical expenses — that’s called coinsurance. Generally, you pay 20% of the
cost of medical services — the Health Fund pays the remaining allowable
charges. You are responsible for paying any amounts over the allowable charges
if you go to a non-network provider. If you go to a provider in the network,
you don’t have to pay any amounts over allowable charges.
A Bit of Information
If you go to a doctor in the PPO network you’ll pay
the $10 copay for the office visit only. You and the Health Fund will split the
allowable charges for the lab fees: you’ll pay 20% and the Health Fund will pay
the remaining 80%.
Your
Expenses Are Limited
The
amount you spend out of your own pocket each calendar year towards allowable
charges for covered expenses is limited to $4,000 for yourself and $6,000 for
you and your family. The limit amount includes your deductible and 20%
coinsurance amount. It doesn’t include the 50% coinsurance amount for mental
health and substance abuse benefits, the 40% coinsurance for dental benefits,
copays, penalties for failure to precertify or amounts in excess of allowable
or R&C charges. The Health Fund will pay 100% of allowable charges after
you reach the applicable limit, so a really serious physical illness or injury
won’t do equal damage to your financial health too.
Keeping Costs Under Control
The
Health Fund pays part of the health care expenses for all eligible active and
retired carpenters and their eligible dependents. To continue to provide health
care benefits to so many people, the Health Fund takes certain steps to keep
costs in line. The first step is to pay only the allowable charges for
medically necessary care.
“Medically
necessary care” must meet three conditions:
All
treatment decisions rest with you and your physician or other health care
provider. You should follow whatever course of treatment you and your
provider believe to be the most appropriate, even if the proposed treatment
is not certified as medically necessary or the Health Fund will not pay
regular benefits for the treatment. Ultimately the decision is yours. A Bit of Information Your doctor may recommend a treatment or procedure
that may not be medically necessary. And a treatment or procedure may be
considered medically necessary but not be covered by the Health Fund. Always
check the lists of services that are covered. Your doctor may be able to
prescribe an alternative treatment or procedure. The
Health Fund also uses case management practices for catastrophic care and a
medical review company for hospital admissions and the length of your stay in
the hospital. Before you or a dependent is admitted to the hospital as an
inpatient, you have to call the medical review company at the number on your
medical ID card to get precertified. You don’t need to precertify
outpatient surgery. If
you’re admitted to the hospital as a result of a medical emergency or treated
in the emergency room, call the medical review company within 48 hours. Precertification
is a way for the Health Fund
to be sure that it’s wisely spending the money entrusted to it for your
benefits, and it saves you money because the Health Fund will pay more for
precertified admissions. If you fail to precertify a hospital admission, the
Health Fund will pay only 70% instead of 80% of the allowable charges. |
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Selecting and Paying For
Care |
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When you go to the doctor, you can select one that’s part of the PPO or not. Suppose you have a pain and go to a doctor. You’ve already paid your deductible and filed a claim form with the Health Fund Office. The Health Fund pays 100% of allowable charges for office visits — minus the $10 copay — and 80% of allowable charges for tests. What impact will your choice of doctor have on your budget? The example below can give you an idea of your costs. The costs used have been created for this example. |
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In the PPO |
Outside the PPO (Non-Network) |
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Charges for office visit |
$150* |
$150 |
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Your payment: copay |
$10 |
$10 |
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Allowable charges |
$100 (PPO contracted rate) |
$130 (R&C charges) |
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Health Fund pays for office visit |
$90 (100% of PPO
contracted rate after copay) |
$120 (100% of R&C
charges after copay) |
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Your payment: amount above allowable
charges |
$0 |
$20 |
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Your total payment for office visit |
$10 |
$30 |
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Billed charges for tests |
$175 |
$175 |
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Allowable charges |
$130 (PPO contracted rate) |
$150 (R&C charges) |
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Health Fund pays for tests |
$104 (80% of $130) |
$120 (80% of $150) |
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Your payment: coinsurance for tests |
$26 |
$30 |
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Your payment: amount above R&C
for tests |
$0 |
$25 |
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Your total payment for tests |
$26 |
$55 |
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Your total payment: office visit and
tests |
$36 |
$85 |
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* This represents the provider’s regular charge
for services that are provided to you at the PPO contracted rate. |
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A Bit of
Information
Work-related screenings and tests and disability exams are not covered.
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Note: If you or your eligible spouse is pregnant, the plan will cover
as surgery the allowable costs of an abortion only if the mother’s life is
endangered. Coverage also is available for a miscarriage, or the medical
complications of an abortion, that happen to you or your eligible spouse.
In the
Hospital
All
in-patient hospital stays for you or any covered dependents require
precertification. You must get precertified before you or any covered
dependents are admitted to the hospital. If you’re admitted to the hospital on
an emergency basis or treated in the emergency room, you have 48 hours to
notify the medical review company at the telephone number on your medical ID
card. If you don’t, you are responsible for paying more of the hospital bill.
Hospital
care includes:
·
semi-private
room and board
·
medically
necessary services and supplies furnished by the hospital
·
prescription
drugs and medications
·
diagnostic
lab and X-ray exams
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X-ray,
radium and radioactive isotope therapy
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anesthetics
and oxygen
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rental
of durable medical or surgical equipment
·
artificial
limbs and eyes
·
blood
transfusions and cost of blood (not including your own blood)
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Service |
You Pay Deductible
Plus |
Health Fund Pays |
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Inpatient and outpatient |
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