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
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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 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.
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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.
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)
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Service |
After Medicare, Health Fund Pays |
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Inpatient
and outpatient |
80%
after deductible |
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Ambulance |
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 |
80%
after deductible Only
for emergency or medical necessity between two facilities which are both
covered Precertification
required unless Medicare is primary |
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Emergency
room |
80%
after deductible |
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Surgical |
80%
after deductible |
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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 |
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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.
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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.
|
Service |
After Medicare, Health Fund Pays |
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Mammogram |
80%
after deductible |
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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 |
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Laboratory
and X-ray |
80%
after deductible |
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Chiropractor/spinal
treatment |
80%
after deductible Up
to first of $2,000 or 31 visits per year, whichever comes first |
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Acupuncture |
80%
after deductible Must
be administered by an M.D. 20
visits per calendar year |
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Sleep
study |
80%
after deductible Need
letter of medical necessity |
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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 |
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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.
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Other The Health Fund covers medical expenses for these other treatments.
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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.
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Mental Health |
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Service |
After Medicare, Health
Fund Pays |
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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 |
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Outpatient |
50%
after deductible 30
visits per calendar year |
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Substance Abuse |
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Service |
After Medicare, Health
Fund Pays |
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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 |
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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 ProgramYour 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 MAPFor 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:
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