Please explain how the Comprehensive Major Medical deductible works. There are five people in my family.
There are 2 types of deductibles within the Comprehensive Major Medical Plan: the Individual Deductible and the Family Deductible. The Individual Deductible is $250. A participant must incur $250 in covered expenses before Comprehensive Major Medical Benefits are payable for that individual. The Family Deductible is met when three (3) of your family members have met their Individual Deductible of $750 during the Calendar Year. After that, no other covered family members will have to meet the Individual Deductible.
The individual deductible for Plan C participants is also $250.
The individual deductible for participants covered under the Retiree Plan is $350.
The individual deductible for participants covered under Plan A is $250.
The individual deductible for participants covered under the Plan C Non Bargained Plan is $500
back to top
What is the out-of-pocket maximum per year?
After the individual deductible is met, the out-of-pocket maximum is $750 per person each calendar year, for covered expenses. The out-of-pocket maximum is not applicable for covered expenses received at Non-PPO Hospitals or Non-PPO Ambulatory Surgical Facilities or for services received from a Non-PPO physician.
The out-of-pocket maximum for participants covered under Plan A is $750.00
The out-of-pocket maximum for participants covered under Plan C is $1,250.
The out-of-pocket maximum for participants covered under the Retiree Plan is $2,000.
The out-of-pocket maximum for participants covered under the Plan C Non Bargained is $1,750.
back to top
What is my coverage if I have an Emergency appendectomy or accident and I’m hospitalized at Non-PPO hospital?
If you are hospitalized or receive treatment for an Emergency (i.e. a sudden and unexpected onset of a traumatic bodily injury or sickness) at a Non-PPO hospital, you will receive the same coverage as if you were treated at a PPO hospital.
back to top
What coverage do I have for Non-emergency treatment of an illness at a Non-PPO Hospital or for surgery performed at a Non-PPO Ambulatory Surgical Facility?
If you receive treatment for a non-emergency treatment of an illness at a Non-PPO Hospital or surgery at a Non-PPO Ambulatory Surgical Facility, the Plan will pay 70% of the ALLOWABLE CHARGE. In addition, Non-PPO charges do not apply to the out-of-pocket maximum.
back to top
Is there a lifetime maximum benefit?
In general, Comprehensive Major Medical lifetime benefits are unlimited. However, limits or maximums may apply to certain benefits, such as Chiropractic Services, Infertility Treatment and the Hospice Benefit.
back to top
My spouse and I were recently divorced, does she remain covered under the Plan?
Your spouse is not eligible for coverage under the Plan as your Dependent as of the date of your divorce or legal separation. Your spouse may be eligible for continuing coverage for 36 months after the divorce or legal separation under COBRA. To be eligible for COBRA coverage, you or your spouse must notify the Fund Office within 60 days of the divorce or legal separation.
back to top
My son is 22 years old and recently graduated from college. Does he still qualify as my dependent for medical coverage?
Yes. Dependent children are covered up to age 26, regardless of whether they are students, reside with you, and/or are married. Please notify the Fund Office if your dependent is covered by another group health plan as his/her own employer’s insurance is primary.
PRESCRIPTION DRUG BENEFIT
back to top
What if I need to start taking a maintenance medication right way?
Ask your doctor for two prescriptions – one for a 30-day supply to be filled immediately at a local pharmacy and a second to be submitted to Express Scripts for a 90-day supply, with appropriate refill instructions.
DENTAL BENEFIT
back to top
My dentist wants to put in a crown. Should my dentist submit a predetermination form to Delta Dental of Illinois?
Yes. The Fund Office wants you to be aware of what benefits will be payable before you have costly dental work done. This way you won’t be surprised by the portion of the bill that is your responsibility.
Plan C participants are not covered under the Dental Plan.
MENTAL AND NERVOUS DISORDERS AND/OR SUBSTANCE ABUSE
back to top
Our doctor recommended a drug addiction treatment program for my son. What coverage is provided for this treatment?
The Plan provides coverage for out-patient or in-patient facility and physician charges for Mental or Nervous Disorders and/or Substance Abuse treatment. To find a PPO Facility or PPO Physician or to find out whether the recommended Provider is in the PPO network, you may contact Blue Cross Blue Shield of Illinois at 1-800-810-2583, visit the Blue Cross Blue Shield of Illinois website at www.bcbsil.com.
back to top
My doctor said I should see a therapist for my depression. What coverage is provided for this treatment?
Coverage will be provided for treatment of a mental or nervous disorder if you see a psychiatrist, psychologist, mental health counselor, substance abuse counselor or social worker with a master’s degree or higher.
back to top
My spouse wants to see a marriage counselor. Is coverage provided for this?
No. This type of counseling is not considered outpatient treatment for a mental or nervous disorder. The Plan only covers Medically Necessary treatment. Marriage counseling is not considered Medically Necessary by the Plan.
SKILLED NURSING FACILITY CARE
back to top
My spouse had a stroke. Now that the crisis stage is over the doctor wants to move her to a skilled nursing home. Are Skilled Nursing Homes covered?
If you or an eligible dependent have been hospitalized, you or your dependent may continue recovery as Inpatient in a Skilled Nursing Facility. Services must be received in a Plan/PPO Skilled Nursing Facility. To verify a facility is a Plan/PPO Skilled Nursing Facility, you may contact Blue Cross Blue Shield of Illinois at 1-800-810-2583, visit the Blue Cross Blue Shield of Illinois website at www.bcbsil.com.
ADMINISTRATIVE INFORMATION
back to top
I would like to have a copy of all the claims my family incurred during the past year. How can I get copies?
You may access your Claims History and view and print your Explanation of Benefits (EOBs) on this website. Click on the Link to https://memberxg.gobasys.com/SMWL73/main/#!/account/login to view your claims.
back to top
I will be in the area of the office next week and would like to stop by the Fund Office to discuss my claims. Is that o.k.?
Please call for an appointment if you feel a visit to the Fund Office is necessary. This will benefit both you and the Fund Office, since the Fund Office personnel will be able to have your records available at the time of your appointment. They will be able to give your problems or concerns prompt attention.
GENERAL EXCLUSIONS AND LIMITATIONS
back to top
I have multiple sclerosis and my doctor indicated that I might need a wheelchair sometime in the future. Would this expense be covered?
If you need Durable Medical Equipment (DME), you should call Med-Care Management to determine if the expense is covered and if so, if the equipment should be rented or purchased. A physician’s prescription of necessity and the length of time you are expected to need the equipment must be submitted to the Fund Office prior to the purchase/delivery of the item. This Plan will purchase such DME in accordance with the Plan’s coverage of only once in an individual’s lifetime. Please note that repairs of the equipment are not covered by the Plan.
back to top