Covered Expenses

The Plan provides a wide variety of services and supplies that are Medically Necessary for treatment of non-work related Sickness and Injuries, unless they are excluded or limited by another Plan provision. These include medical care by Hospitals, Doctors and other healthcare Providers, as well as diagnostic tests and procedures used in treatment.

The following expenses are covered under the Comprehensive Major Medical Benefit if they are Reasonable and Customary charges, are Medically Necessary (see Definitions) and are services and supplies provided for the treatment of non-occupational Sicknesses or Injuries:

1. Hospital charges for daily board and bed or room, up to the Hospital’s regular daily rate for semi-private accommodations. The Plan will cover the expense of a private room if semi-private accommodations are not available.
    

2. Hospital specialty care unit charges (intensive care unit or cardiac care unit).
    

3. Charges, other than charges for regular daily services, made by a Hospital for medical care and treatment, exclusive of charges for professional services, including Medically Necessary ancillary services (e.g. prescriptions, supplies).
    

4. Ambulatory Surgical Facilities expenses
    

5. Professional local ambulance service charges for transportation to a Hospital. Transportation by air ambulance is covered if Medically Necessary
    

6. Charges made by a licensed Physician for medical care and treatment and for performing a surgical procedure or a laparoscopic procedure.
    

7. Charges made by a Registered Nurse (RN) during Hospital confinement for private nursing service, provided the attending Physician prescribes in writing the need for services of a registered nurse. In addition, only a coordinated home care program provided by an RN that is Medically Necessary (not custodial-type care) and that replaces or reduces confinement in a Hospital or Skilled Nursing Facility will be covered.
    

8. Charges made by a person who is legally licensed as a Licensed Practical Nurse (LPN) during Hospital confinement, provided a registered nurse is not available and the attending Physician prescribes the services of an LPN. In addition, services of an LPN for home care will be covered if the services are Medically Necessary and are rendered under the direction of a Physician or RN.
    

9. Charges made for the cost and personal administration of an anesthetic by a Physician who remains in constant attendance during a surgical procedure for the sole purpose of rendering an anesthetic
    

10. Charges made for the cost and personal administration of an anesthetic by a person legally licensed as a Certified Registered Nurse Anesthetist (CRNA) under the supervision of a Physician who remains in constant attendance during a surgical procedure for the sole purpose of rendering an anesthetic. A Certified Registered Nurse Anesthetist includes a person legally licensed as a Certified Registered Nurse Anesthetist, Registered Nurse Anesthetist, or Nurse Anesthetist, who is authorized to administer anesthesia in collaboration with a Physician, and bill and be paid in the Nurse Anesthetist’s own name, or any equivalent designation, under the laws of the state or jurisdiction where the services are rendered, who acts within the scope of the Nurse Anesthetist’s license and who is not the patient or the parent, spouse, sibling (by birth or marriage) or child of the patient

11. Charges made for radium therapy, x-ray treatments and examinations, microscopic tests or any laboratory tests or analyses made for diagnostic or treatment purposes. No benefits will be payable for dental x-rays or x-rays for eye refractions, except in cases of bodily Injury.
     

12. Charges made for treatment by a person legally licensed as a professional physical, occupational, or speech therapist who acts within the scope of his/her license. Physical, occupational, and speech therapy are benefits that can be subject to medical review. This means that your Physician or you must contact the Fund Office regarding physical, occupational, and/or speech therapy. The Fund Office requires that your Physician provide a letter indicating that the therapy is Medically Necessary, and proposing your treatment plan. The Fund Office will then have the therapy and the length of treatment approved by one of its Contracted Medical Claim Review Providers. Ongoing therapy may also be sent for review by the Plan’s Contracted Medical Claim Review Provider.
     

13. Charges made by a person legally licensed as a doctor of chiropractic medicine (DC) who acts within the scope of his/her license, as provided in the Schedule of Benefits and subject to a calendar year maximum shown in the Schedule of Benefits.
     

14. Charges made by a person legally licensed as a doctor of osteopathic medicine (DO) who acts within the scope of his/her license, in accordance with the Schedule of Benefits.
     

15. Charges made by a Physician for Inpatient or Outpatient treatment of Mental or Nervous Disorders and/or Substance Abuse not to exceed the maximums shown in the Schedule of Benefits 
     

16. Charges made by a Dentist for the performance of oral surgery, consisting of cutting procedures for the treatment of diseases or injuries of the jaw or extraction of impacted teeth, provided that such oral surgery is performed during a period of confinement of at least 18 hours in a legally constituted and operating Hospital.
     

17.  Gastric By-Pass procedures to treat morbid obesity, provided the following criteria are met:    
     

    • The patient’s Body Mass Index (BMI) is greater than or equal to 50, or  
       

    • The patient’s Body Mass Index (BMI) is greater than or equal to 45 with two or more co-morbidities that immediately endanger the patient’s well-being. Co-morbidities include hypertension, diabetes, dyslipidemia, sleep apnea and coronary heart disease.
       

    • The Gastric By-Pass procedure must be performed by a PPO Physician at a PPO surgical facility. The Plan will make no payment for Gastric By-Pass procedures that are performed by a non-PPO Physician or for Gastric By-Pass procedures that are performed at a non-PPO facility.
       

18. Rental or, if approved by the Fund Office, the purchase of Durable Medical Equipment (DME) which is Medically Necessary for treatment of a Sickness or disability. To be eligible for coverage:
     

    • The equipment must meet the Plan’s definition of (DME).
       

    • The equipment must be ordered by a Physician who must certify the necessity of the equipment and indicate how long the equipment will be needed. This written order must be submitted to the Fund Office and must include a complete diagnosis and treatment plan so the Fund Office can determine whether purchase or rental of the Medically Necessary equipment is more cost-effective.
       

    • You must submit an itemized bill from the company supplying the equipment showing the date the equipment was delivered and the full rental or purchase price.

 

The Plan will cover one item of the same or similar DME every 5 years (measured from the DME’s initial rental or purchase date) for each eligible person.

The items listed in Appendix A are considered DME or covered supplies for which benefits may be payable if all other conditions to entitlement are satisfied. The items listed as Non-Covered are not considered DME or a covered supply.

The Trustees will have the authority and discretion to determine what is considered DME and covered supplies for items not listed and when to rent, lease or purchase the equipment.

For the purpose of determining the Reasonable and Customary charge for the purchase of DME, the Trustees may ascertain the wholesale cost of the basic model for the same or similar equipment.

The Trustees have the authority to authorize additional payment if, in their opinion, such additional payment is reasonable.

Repairs of DME are not considered covered expenses.

19. Radiation therapy and chemotherapy treatments.
     
20. Renal dialysis treatments are covered if you receive them in a Hospital, a Plan Approved Dialysis Facility or in your home under the supervision of a Hospital or Plan Approved Dialysis Facility.
     

21. Skilled Nursing Facility Care
     

    • Admission to a Plan/PPO Skilled Nursing Facility is considered a continuation of your Inpatient Hospital stay and payment will be the same as that previously described for Inpatient covered services.
       
    • If you have been hospitalized, you may continue your recovery as an Inpatient in a Skilled Nursing Facility. You must be admitted for the same diagnosis as the Hospital admission within 14 days of leaving the Hospital or a coordinated home care program.
       
    • Services must be received in a Plan/PPO Skilled Nursing Facility.  Benefits are not available for services received in a Non-Plan Skilled Nursing Facility. Contact the Fund Office before admission to a Skilled Nursing Facility to verify that the facility is a Plan/PPO Skilled Nursing Facility (Definitions)
       
    • Covered services in a Plan/PPO Skilled Nursing Facility include:
       
      1. Bed, board and general nursing care.
          
      2. Ancillary services (such as drugs and surgical dressings and supplies).
         ​
22. Pre-Admission Testing.
     
23. Human Organ Transplants. Benefits will be provided only for cornea, kidney, bone marrow, heart valve, muscular-skeletal, parathyroid, heart, lung, heart/lung, liver, pancreas or pancreas/kidney human organ or tissue transplants. Benefits are available to both the recipient and donor of a covered transplant as follows:
     
    1. The Fund’s deductible and coinsurance provisions do not apply to expenses of covered transplants received at Blue Cross Blue Shield Centers of Excellence facilities.
        
    2. If both the donor and recipient have coverage, each will have their benefits paid by their own program.
        
    3. If you are the recipient of the transplant and the donor for the transplant has no coverage from any other source, the benefits described in this benefit booklet will be provided for both you and the donor. In this case, payments made for the donor will be charged against the recipient’s benefits.
        
    4. If you are the donor for the transplant and no coverage is available to you from any other source, the benefits described in this benefit booklet will be provided for you; however, no benefits will be provided for the recipient.
        
    5. In addition to the above provisions, benefits for heart, lung, heart/lung, liver, pancreas or pancreas/kidney transplants will be provided as follows:
        
       1. Benefits under this coverage will begin no earlier than 5 days prior to the transplant surgery and will continue for a period of no longer than 365 days after the transplant surgery. Benefits will be provided for all Inpatient and Outpatient covered services related to the transplant surgery in accordance with the Schedule of Benefits.
           
       2. Benefits will also be provided for the transportation of the donor organ to the location of the transplant surgery. Benefits will be limited to the transportation of the donor organ in the United States or Canada.
    6. In addition to the other exclusions of this benefit booklet, benefits will not be provided for the following:
        
       1. Cardiac rehabilitation services when not provided to the transplant recipient within 3 days after discharge from a Hospital for transplant surgery.
           
       2. Transportation by air ambulance for the donor or the recipient.
           
       3. Travel time and related expenses required by the Provider.
           
       4. Drugs that are investigational, as determined by Blue Cross Blue Shield of Illinois.
           
24. Maternity services as follows:
     
    1. Benefits for maternity services are the same as benefits for any other condition.
        
    2. Benefits provided for you and your Dependents including your Dependent Child.
        
    3. Benefits will be paid for covered services received in connection with both normal pregnancy and complications of pregnancy. Maternity service benefits will also be provided for the routine Inpatient nursery charges (such as room and board, infant feedings, etc.). Coverage also includes benefits for elective abortions if legal where performed.
        
    4. Your Eligible Dependent Child is covered for prenatal and delivery expenses incurred as a result of the birthing process only. No other maternity or newborn charges will be considered covered expenses for your Dependent Child or the newborn Child.
        
    5. Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any Hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a Cesarean Section. However, Federal law generally does not prohibit the mother’s or newborn’s attending Physician, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not require that a Provider obtain authorization from the Fund or the insurance issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).
25. The necessary care and treatment of medically diagnosed congenital defects and birth abnormalities of your newborn Child. In addition, benefits will be payable with respect to expenses incurred as a result of routine nursing care, routine well baby care, immunizations and medical exams or tests.
     
26. Administration of blood transfusions.
     
27. Surgical sterilization charges.
     
28. Routine child and adolescent immunizations and routine Physician examinations or check-ups (until the Child’s 26th birthday) for eligible Dependents.
     
29. Reconstructive breast surgery and breast prosthesis following a mastectomy including:
    1. Reconstruction of the breast on which the mastectomy was performed,
        
    2. Surgery and reconstruction of the other breast to produce a symmetrical appearance, and
        
    3. Prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas.
30. Hospice expenses, in accordance with the Hospice Benefit.
     
31. Infertility treatment including in vitro fertilization (IVF), embryo transfer, artificial insemination (AI), interine embryo lavage, gamete intrafallopian tube transfer (GIFT), zygote intrafallopian tube transfer (ZIFT), lower tubal transfer and Prescription Drugs related to the treatment of infertility, subject to the limits contained in the Schedule of Benefits.
     
32. Vision therapy to improve and correct vision problems rendered by an optometrist or orthoptic technician for certain limited conditions. The diagnosis must indicate a structural or physical disorder of the eye or eye muscles, such as:
     
    1. Accommodation inability (non-presbyopic),
        
    2. Amblyopia (resulting from disuse/exanopsia), and
        
    3. Binocular dysfunction, including:
        
       1. Convergence/divergence insufficiency (heterophorias: esophoria and exophoria),
           
       2. Strabismus, accommodative (heterotropias: esotropia and exotropia), and
           
       3. Myopia, functional (excessive convergency).
           
33. Out-of-network claims of an emergency nature that provide no reasonable opportunity to safely utilize a PPO Provider will be processed as follows:
     
    1. The claim will be sent by the Fund Office to its Contracted Medical Claim Review Provider for re-pricing based on Reasonable and Customary charges at the 90^th percentile.
        
    2. After the claim is re-priced by the Contracted Medical Claim Review Provider, the resulting charges will be processed at the appropriate in-network rate.
        
    3. Payment of the claim will be based on Reasonable and Customary charges at the 90^th percentile and paid at the appropriate in-network rate for the initial emergency claim, as well as surgical follow-up care.
        
    4. Claims for out-of-network services that are provided after you have a reasonable opportunity to safely utilize a PPO Provider will be treated as Non-PPO claims.
        
34. The first pair of eyeglasses purchased after cataract surgery.
     
35. Charges for certain Non-Physician Providers:
     
    1. Charges made by a Physician Assistant (PA) who meets all of the following requirements:
        
       1. who is legally licensed as a Physician Assistant in the State in which services are furnished;
           
       2. who acts within the scope of his or her license;
           
       3. who is not the patient or the parent, spouse, sibling (by birth or marriage), or child of the patient; and     
           
       4. who acts under the supervision of a Physician.
          
          Coverage is limited to services that are of the type that would be considered physician’s services if furnished by a physician and that a Physician Assistant is legally authorized to perform under applicable State Law.
           
    2. Charges made by a Nurse Practitioner (NP) who meets all of the following requirements:
        
       1. who is a registered professional nurse authorized by the State in which the services are furnished to practice as a Nurse Practitioner;
           
       2. who is certified as a Nurse Practitioner by a recognized national certifying body that has established standards for Nurse Practitioners;
           
       3.  who has a master’s degree in nursing; who acts within the scope of his or her license;
           
       4.  who is not the patient or the parent, spouse, sibling (by birth or marriage), or child of the patient; and
           
       5.  who acts in collaboration with a Physician.
          
          Coverage is limited to services that would be considered physician’s services if furnished by a physician and that a Nurse Practitioner is legally authorized to perform under applicable State Law.
    3. Charges made by a Certified Nurse-Midwife (CNM) who meets all of the following requirements:
        
       1. who is licensed to practice in the State in which the services are furnished as a registered professional nurse;
           
       2. who is either (A) legally authorized in the State to practice as a nurse-midwife and has completed a program of study and clinical experience for nurse-midwives as specified by the applicable State or (B) if the applicable State does not specify a program of study and clinical experience for nurse-midwives, then the nurse-midwife must either (1) be currently certified as a nurse mid-wife by the American College of Nurse-Midwives, (2) have satisfactorily completed a formal education program (of at least one academic year) that, upon completion, qualifies the nurse to take the certification examination offered by the American College of Nurse-Midwives, or (3) have successfully completed a formal education program for preparing registered nurses to furnish gynecological and obstetrical care to women during pregnancy, delivery, and the postpartum period, and care to normal newborns, and have practiced as a nurse-midwife for a total of 12 months during any 18-month period from August 8, 1976 to July 16, 1982;
           
       3. who acts within the scope of his or her license; and
           
       4. who is not the patient or the parent, spouse, sibling (by birth or marriage), or child of the patient.
          
          Coverage is limited to services that would otherwise be covered if furnished by a physician and that a Certified Nurse-Midwife is legally authorized to perform under applicable State law.
    4. Charges made by a Clinical Nurse Specialist (CNS) who meets all of the following requirements:
        
       1. who is a registered nurse currently licensed to practice in the State where he or she practices;
           
       2. who is authorized to furnish the services of a Clinical Nurse Specialist under applicable State law;
           
       3. who has a master’s degree in a defined clinical area of nursing from an accredited educational institution;
           
       4. who is certified as a Clinical Nurse Specialist by a recognized national certifying body that has established standards for Clinical Nurse Specialists;
           
       5. who acts within the scope of his or her license;
           
       6. who is not a patient or the parent, spouse, sibling (by birth or marriage), or child of the patient; and (vii) who acts in collaboration with a Physician.
          
          Coverage is limited to services that would be considered physician’s services if furnished by a physician and that a Clinical Nurse Specialist is legally authorized to perform under applicable State law.
           
    5. Charges made by a certified/registered Surgical Assistant who meets all of the following requirements:
        
       1. who is legally licensed as a Surgical Assistant in the State in which services are furnished;
           
       2. who acts within the scope of his or her license;
           
       3. who is not the patient or the parent, spouse, sibling (by birth or marriage), or child of the patient; and
           
       4. who acts under the supervision of a Surgeon.
          
          Coverage is limited to services that are of the type that would be considered surgical services if furnished by a Surgeon and that a Surgical Assistant is legally authorized to perform under applicable State law.
           
36. Diabetes counseling services, when ordered by a Physician and performed by a provider licensed 
    to perform such services under applicable law, including self-management training, education,  equipment and supplies for the treatment of diabetes, and medical nutrition therapy (MNT), as  provided below:
    
    a)         Up to 3 visits following initial diagnosis of diabetes; a
    
    b)         Up to 2 additional visits if a Physician has determined there has been a significant change in
                 patient’s symptoms.
    
    Benefits are limited to services that are Medically Necessary. Certain benefits must be approved by the Blue Cross Blue Shield MSA or the Fund Office and its Contracted Medical Claim Review Provider. In the event the service or procedure is not covered by the Schedule of Benefits, it will not be covered.