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.
·
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
·
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 |
20% of: $17,500 (individual) or $25,000 (family) |
With precertification: 80% after deductible of first $17,500
(individual) or $25,000 (family), then 100% Without precertification: Same as above, but 70% instead of 80% Note: the 10% penalty is not included in
limiting your out-of-pocket expenses |
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Ambulance |
20% plus any amount over allowable charges if
non-network |
80% after deductible Only for emergency or medical necessity to the
nearest facility or between two facilities to obtain covered services |
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Air ambulance |
20% plus any amount over allowable charges if
non-network |
80% after deductible Only for emergency or medical necessity Precertification required |
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Emergency room |
$50, waived if admitted, then 20% |
80% after deductible |
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Surgical |
20% plus any amount over allowable charges if
non-network |
80% after deductible |
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Voluntary sterilization procedure |
20% plus any amount over allowable charges if
non-network |
80% after deductible Member or spouse only |
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Abortion |
20% plus any amount over allowable charges if
non-network |
80% after deductible ·
Member
or spouse only ·
Only
if the mother’s life is endangered ·
Medical
complications |
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Breast reconstruction after mastectomy |
20% plus any amount over allowable charges if
non-network |
80% after deductible ·
Reconstruction
of breast that was operated on ·
Surgery
on the other breast to produce a symmetrical appearance ·
Prostheses
(gel implants every five years) ·
Bras
(one every calendar year) ·
Physical
complications |
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A Bit of Information
Suppose your daughter needs to be hospitalized for a
$5,000 operation. The Family Deductible has been met.
If you call to get precertification for the
operation, your share of the allowable charges will be 20% of $5,000, or
$1,000. If you don’t do this, your share of the cost will be 30%, or $1,500.
For spending some time on the phone notifying the
medical review company, you’ll get $500 more in benefits. Precertification is
worth your time.
Rehabilitation
If
a medical condition requires more than a hospital visit, the Health Fund covers
rehabilitative treatments in a licensed rehabilitation unit of an acute care
facility, rehabilitation hospital, or a rehabilitation unit in a skilled
nursing facility. Custodial, intermediate and skilled levels of care are not
covered as rehabilitation.
No
benefit will be paid if you do not get pre-certification.
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Service |
You Pay Deductible
Plus |
Health Fund Pays |
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Inpatient and outpatient |
20% plus any amount over allowable charges if
non-network |
80% after deductible ·
Up
to 120 days per calendar year ·
Must
be an approved facility ·
Precertification
required: call the number on the back of your I.D. card |
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Outpatient physical therapy/occupational
therapy |
$10 for one annual office visit/evaluation,
then 20% plus any amount over allowable charges if non-network |
80% after deductible 45 visits per calendar year |
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Speech therapy |
20% plus any amount over allowable charges if
non-network |
80% after deductible Only to restore speech after stroke,
accidental injury or removal of vocal chords |
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Cardiac rehabilitation |
$10 for one annual office visit/evaluation,
then 20% plus any amount over allowable charges if non-network |
80% after deductible ·
Must
be within 26 weeks of diagnosis or event ·
Up
to six months ·
Must
be an approved facility |
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Orthoptic therapy |
$10 for one annual office visit, then 20% plus
any amount over allowable charges if non-network |
80% after deductible Up to 25 visits per calendar year |
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Medical
Services If
you or your doctor suspects a medical problem, check it out. If you have a
problem, treat it. The Health Fund covers tests and procedures.
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Other
The Health Fund also covers medical expenses for the
following treatments.
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Service |
You Pay Deductible
Plus |
Health Fund Pays |
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Home health care |
20% plus any amount over allowable charges if
non-network |
80% after deductible Care given by a Registered Nurse, Physical
Therapist or Occupational Therapist Up to 80 visits of four hours per day per
calendar year |
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Home health aide |
20% plus any amount over allowable charges if
non-network |
80% after deductible Care given by a someone other than a
Registered Nurse or Licensed Practical Nurse Up to 80 visits of four hours per day per
calendar year |
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Hospice |
Nothing — there is no deductible |
100% Inpatient and outpatient Terminal illness, prognosis is six months or
less |
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Durable medical equipment |
20% plus any amount over allowable charges if
non-network |
80% after deductible Rental paid up to purchase price Replacement for growth if new prescription Need letter of medical necessity and itemized
breakdown Maximum of $5,000 per individual per calendar
year |
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Glasses after cataract surgery |
20% plus any amount over allowable charges if
non-network |
One pair following surgery No more than one pair per calendar year |
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Orthotics |
20% plus any amount over allowable charges if
non-network |
80% after deductible ·
One
per lifetime ·
Need
biomechanical results |
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Orthopedic shoes |
20% plus any amount over allowable charges if
non-network |
80% after deductible Initial purchase of one pair Replacement if prescription changes Replacement after 12 months (not for wear and
tear) |
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Supplies |
20% plus any amount over allowable charges if
non-network |
80% after deductible Surgical stockings: two pairs per lifetime Disposable supplies not covered |
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Organ Transplants: ·
Bone
marrow ·
Cornea ·
Kidney ·
Liver ·
Heart ·
Heart-lung ·
Pancreas |
20% plus any amount over allowable charges if
non-network |
80% after deductible Must be performed at a United Resource Network
Center of Excellence or it will be covered at the same rate and capped if
performed elsewhere Limits apply to combination of evaluation and
surgery |
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Transplant expense reimbursement |
Amounts in excess of what the Health Fund pays |
Round trip coach airfare for patient and companion,
if necessary Lodging at $85 per night up to 30 nights Daily living expenses at $40 per day for
patient and companion up to 30 days Must be approved in advance |
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A Bit of Information If you or a dependent needs an organ transplant,
the Health Fund wants to be sure you consider having the operation performed
at a Center of Excellence. What’s that? It’s a facility that meets the
quality measures set up by the American Medical Association for its
experience, expertise, patient outcome and cost effectiveness. The Health
Fund uses independent consultants to recommend and evaluate centers. Mental Health and Substance Abuse You and your dependents can get help for
mental health or substance abuse problems. The lifetime limit for inpatient
or outpatient substance abuse is $20,000 — including Weekly Disability Income
(WDI) — or two episodes per lifetime, whichever comes first.
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A Bit of Information
If you or a covered loved one is incapacitated by or
dependent on drugs or alcohol, more than detoxification may be needed. That’s
why substance abuse treatment covers a whole course of treatment, prescribed by
a physician, which evaluates the problem, gives necessary medical, psychiatric
or psychological care and provides counseling and rehabilitation.
Member Assistance Program
Your benefits include the Member Assistance
Program (MAP) for help with:
·
daily
troubles that become overwhelming,
·
mental
health care, or
·
substance
abuse treatment.
Need Help? Use the MAP
For
problems that threaten your peace of mind or quality of life, you can get help.
Call 1.800.417.0574. You or your eligible family members can each have up to
eight visits as an outpatient with a trained professional at no cost to you. If
you need further treatment a referral will be made to another provider and you
may be covered under the Mental Health benefits.
Counselors
are available 24 hours a day to help with these and other issues:
- aging
- alcohol and drug abuse
- career and job issues
- child care concerns
- depression
- domestic abuse
- elder care concerns
- financial or legal
concerns
- gambling or other
compulsive behavior
- marital and family
problems
- psychological and
emotional struggles
- stress and anxiety
- suicidal thoughts
The
MAP program is administered by ETP, Inc., which is an independent and separate
company. It is not affiliated with or under the control of the Health Fund.
This means that the Trustees can’t take responsibility for the results of
counseling received through ETP, Inc. or interfere in the professional
relationship that exists between patient and counselor.
All
consultations are confidential.
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What
Isn’t Covered? The Health Fund does not cover all medical and health services. And some services that are covered have certain conditions that apply to them. This chart lists services and treatments that are not covered by the Health Fund. It contains items that are listed as covered elsewhere in this book because circumstances or limitations may apply to some treatments. If you have any confusion about any medical treatment you’re considering, please call the Health Fund Office.
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What’s
Not Covered |
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Elective surgical or medical abortion unless mother’s life is
endangered ·
Routine examinations that have not been described as covered ·
Physical examinations required by an employer as a condition of
employment or by a school or camp as a condition of enrollment or
participation ·
Immunizations that have not been described as covered ·
Organ transplants that have not been described as covered ·
Organ donation to anyone who is not covered under the Health Fund ·
Hearing aids unless required due to accidental injury ·
Testing or repairing hearing aids ·
Transportation that has not been described as covered ·
Paramedic services, except given in a covered ambulance service in an
emergency ·
Blood and blood plasma donated, replaced or stored for future use ·
Repair or replacement of prosthetic devices or medical equipment due
to wear and tear or breakage ·
Orthotic or arch supports for engaging in sports ·
Marriage counseling ·
Educational therapy for correction of learning disabilities ·
Homemaker or housekeeping services ·
Speech therapy ·
Psychological, personality or perceptual tests ·
Mental, psychoneurotic or personality disorders while not hospital
confined ·
Convalescent facilities, nursing homes, half-way houses, residential
treatment centers ·
Prescription drug costs for anyone who has primary coverage from
another plan ·
Vision care costs for anyone who has primary coverage from another
plan ·
Treatment of teeth or gums — (see the dental benefits) ·
Medical services or supplies outside the US or Canada, except for
medical emergency ·
Services rendered by you or your spouse, parent, brother, sister or
child ·
Expenses incurred after you settle any third-party or insurance claim
related to an injury or illness for which a third party may be responsible ·
Services or supplies payable by a government or governmental agency,
including Medicare ·
Confinement in a hospital which is owned and operated by the Federal
government ·
Penalties or exclusions incurred because you didn’t follow another
medical plan’s rules ·
Complications arising from non-covered services ·
Court ordered confinements or treatments not covered by the Health
Fund ·
Treatment in connection with participation in a felony, riot or
insurrection ·
Treatment of injury or illness arising out of war (declared or undeclared)
including armed aggression ·
Artificial limbs, unless loss was a result of accidental injury ·
Use of a physician’s suite, surgical trays, nurse assistance,
disposable supplies, sterile gloves and other items ·
Biohazardous waste disposal ·
Review of past medical history ·
Preparation of medical reports, bills, insurance or claim forms;
mailing, shipping or handling expense; charges for broken appointments,
telephone calls or photocopying fees ·
Sales tax or any state tax or surcharge |