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 – Supplemental Plan

You and your dependents need affordable, quality health care. The Health Fund’s goal is to help you obtain it, with benefits that range from preventive examinations and tests to organ transplants.

If you’re at least age 65, you’re eligible for Medicare. If you’re any age and disabled, you may also be eligible for Medicare. Medicare is your primary coverage in most cases. You will always be given full information from the Health Fund about the medical plan under which it covers you.

You have a one-time option to select coverage under the Retiree Full or Retiree Reduced plan. If you select the Retiree Full Plan, you can later elect to change to the Retiree Reduced Plan. You can’t change from the Retiree Reduced Plan to the Retiree Full Plan.

You must enroll in Medicare parts A and B. If you don’t have part B, the Health Fund estimates what Medicare would have paid you and pays you a percentage of the balance. Instead of full coverage, you receive only a small reimbursement on the amount you paid for your care.

If a provider is not participating with Medicare, Medicare will deny the claim. The Health Fund estimates what Medicare would have paid you, and pays you a percentage of the balance.

Medical Benefits

Supplemental Plan

Retiree Reduced

Lifetime Maximum

The Health Fund limits the amount of benefits it will pay under the Supplemental Plan to $50,000 per person, per lifetime. You cannot carry over any unused amounts from the Full Plan lifetime maximum. Each calendar year, any benefits paid to you in the previous calendar year ― up to $1,000 ― are added back into your remaining lifetime maximum. You cannot have more than $1,000 restored to your lifetime maximum in any one calendar year.

What You Pay For

Deductible

Before the Health Fund pays for your covered medical expenses, you pay for your medical care up to a deductible of $100 per person per year.

Copay

There is no separate copay under the Supplemental Plan other than the Medicare copay.

Coinsurance

After you’ve met the deductible, the Health Fund pays 80% of Medicare’s balance that was not paid to you by Medicare. You are responsible for amounts not covered by Medicare or the Health Fund.

Coordinating Your Benefits With Your Medicare Coverage

The Health Fund calculates what it will pay for your care by looking at the Medicare statement of benefits and paying 80% of the balance due for covered services.

A Bit of Information

If you have questions about your coverage under the Health Fund, please call the Health Fund Office at 1.800.922.6026.

If you have questions about Medicare, call 1.800.MEDICARE (1.800.633.4227).

You can also get Medicare information on the Internet at www.medicare.gov. If you don’t have a computer at home, you may be able to go online at your local library or community center.

Medical Benefits

You and your covered dependents have comprehensive coverage for your medical needs.

Note: The Health Fund pays a percentage of charges allowed by Medicare or an amount up to a dollar limit after you meet the deductible and after Medicare pays its portion.

In the Doctor’s Office

Stay healthy — take advantage of the coverage for the following services.

Service

After Medicare, Health Fund Pays

Immunizations

Lyme Disease Vaccine

Influenza Vaccine

Pneumococcal Vaccine

100% of allowable charges:

· Series of three shots once every 10 years

· One shot annually

Medicare is primary

Allergy treatment

80% after deductible

Keeping Costs Under Control

The Health Fund pays part of the health care expenses for all eligible active and retired carpenters and their dependents. To continue to provide health care benefits to so many people, the Health Fund takes certain steps to keep costs in line.

One step is to rely on Medicare limits to determine whether the care is medically necessary, appropriate and allowable. Another step is using a medical review company for rehabilitative care. It’s simple: if you or a dependent will need more than 20 days of inpatient rehabilitation — which is paid for by Medicare — call the number on your medical ID card to notify the medical review company and get precertified. You must call before you have more than 20 days of care.

Precertification is a way for the Health Fund to be sure that it’s wisely spending the money entrusted to it for your benefits. Rehabilitative admissions are not paid for at all if they are not precertified.

In the Hospital

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

· X-ray, radium and radioactive isotope therapy

· 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)

Service	After Medicare, Health Fund Pays
Inpatient and outpatient	80% after deductible
Ambulance	80% after deductible Only for emergency or medical necessity to the nearest facility or between two facilities to obtain covered services
Air ambulance	80% after deductible Only for emergency or medical necessity between two facilities which are both covered Precertification required unless Medicare is primary
Emergency room	80% after deductible
Surgical	80% after deductible
Breast reconstruction after mastectomy	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

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 precertification.

Service	After Medicare, Health Fund Pays
Inpatient	80% after deductible Up to 120 days per calendar year Must be an approved facility Precertification required on first day if level of care is rehabilitative or 21^st day if Medicare pays. Call the number on your medical ID card
Outpatient physical therapy/occupational therapy (PT/OT)	80% after deductible
Speech therapy	80% after deductible Only to restore speech after stroke, accidental injury or removal of vocal chords
Cardiac rehabilitation	80% after deductible
Orthoptic therapy	80% after deductible

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.

Service	After Medicare, Health Fund Pays
Mammogram	80% after deductible
Hearing test/evaluation	80% after deductible Must be performed by an M.D. only Hearing aids are not covered unless hearing loss is caused by accidental injury
Laboratory and X-ray	80% after deductible
Chiropractor/spinal treatment	80% after deductible Up to first of $2,000 or 31 visits per year, whichever comes first
Acupuncture	80% after deductible Must be administered by an M.D. 20 visits per calendar year
Sleep study	80% after deductible Need letter of medical necessity
Continuous Positive Airway Pressure (CPAP) machine/two masks	80% after deductible Need results of two sleep studies done on different days and letter of medical necessity Two masks per calendar year
Biofeedback	80% after deductible

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.

Other

The Health Fund covers medical expenses for these other treatments.

Service	After Medicare, Health Fund Pays
Home health care	80% after deductible Up to 80 visits of four hours per day per calendar year
Hospice	80% after deductible
Durable medical equipment	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 year
Glasses after cataract surgery	80% after deductible One pair following surgery No more than one pair per calendar year
Orthotics	80% after deductible
Orthopedic shoes	80% after deductible Initial purchase of one pair Replacement if prescription changes Replacement after 12 months (not for wear and tear)
Supplies	80% after deductible Surgical stockings: two pair per lifetime Disposable supplies not covered
Organ Transplants: · Bone marrow · Cornea · Kidney · Liver · Heart · Heart-lung · Pancreas	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
Transplant expense reimbursement Evaluation and surgery combined	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
Prescription drugs	80% after deductible Includes oral contraceptives

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. If Medicare is primary, you do not need to precertify procedures.

Mental Health
Service	After Medicare, Health Fund Pays
Inpatient and/or partial hospitalization	With precertification: 80% after deductible Without precertification: Same as above but 70% instead of 80% 60 days per calendar year For precertification call the number on the back of your I.D. card
Outpatient	50% after deductible 30 visits per calendar year

Substance Abuse
Service	After Medicare, Health Fund Pays
Inpatient	With precertification: 80% after deductible Without precertification: Same as above but 70% instead of 80% 45 days or $20,000 whichever comes first Does not cover detoxification alone $20,000 combined in/patient lifetime limit and WDI benefit or two episodes per lifetime For precertification call the number on the back of your I.D. card
Outpatient (includes partial hospitalization)	50% after deductible 30 visits per calendar year, includes partial hospitalization $20,000 combined in/outpatient lifetime limit and disability benefits or two episodes per lifetime

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 1.888.373.5073. 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 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.

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 apply to some treatments. If you have any confusion about any medical treatment you’re considering, please call the Health Fund Office.

What’s Not Covered

· Services that aren’t medically necessary

· Amounts above Allowable Charges

· Any services or supplies that are not required by a certified physician

· Treatment or services given by a provider who does not meet the Health Fund’s definition of a provider

· Experimental, investigational or unproven medical procedures, treatments, devices, drugs or services

· Injuries or diseases sustained in any occupation or employment for pay or profit

· Injuries or diseases covered by any workers’ compensation law

· Services for the first 12 months of coverage for any sickness, injury or condition for which treatment was received in the six months prior to being covered by the Health Fund, unless there is creditable coverage under another group health plan

· Contraceptives and birth control devices prior to 2001

· More than one voluntary sterilization procedure

· Reversal of elective sterilization

· Pregnancy, diagnostic tests, abortion, contraceptives or other related charges of a dependent child

· Childbirth classes

· Genetic counseling or treatment of genetic disorders

· Infertility treatment (in-vitro/in-vivo fertilization and drugs)

· Screening and selection of potential artificial insemination donors

· Surrogate motherhood, or insemination of a surrogate mother

· Cosmetic surgery, except to repair damage as a result of accidental injury

· Exercise classes

· Figure salons

What’s Not Covered

· Resorts, spas, camps or weight reducing programs or clinics

· Membership fees

· Reike or any form of energy healing

· Growth hormone deficiency treatment

· Hair loss, hair removal or hair transplants

· Wigs, except if needed due to chemotherapy or radiation therapy, then one per calendar year

· Routine foot care (trimming nails, removing corns or calluses)

· Obesity, including surgery and surgical complications

· Hypnosis for weight loss, personal problems or smoking cessation

· Nutritional counseling, unless for a pregnant, diabetic member or spouse

· Wiring teeth for weight reduction

· Autopsy

· Custodial care

· Treatment of a narcotic habit, unless the drugs were given by a physician

· Methadone maintenance

· Detoxification

· Transsexualism (sex reassignment procedures, services, supplies or medications)

· 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

What’s Not Covered

· 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, except for accidental injury

· 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

· Charges 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