 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
MEDICAL BENEFITS QUESTIONSDo I need to pre-certify for outpatient procedures? What is the medical deductible? What
are maximum out-of-pocket expenses? For emergency room care, am I responsible for a co-pay?Are
routine medical exams covered? What
else is covered under the Wellness Benefit? Why do I get letters when I file a claim? What do I need to provide when there is a change of Family Status? How long are my dependents covered? Do I need to notify the Fund each semester that they are continuing as a full-time student? PRESCRIPTION BENEFITS QUESTIONS For retail prescription refills, can I still go to Walgreens? I submitted a mail-order prescription in July to Walgreens (WHI). Will MEDCO be able to process it? Will my prescription benefits be the same on this new plan? Will I have one card to present for prescription and medical benefits? Can I order additional cards for family members? What is the dental deductible? Are braces/orthodontics covered under the dental plan? Can I get a pre-estimate on extensive dental work from the Fund? Are routine vision benefits covered? How do I get a refund if I use an out-of-network vision provider? Are VSP in-network providers also contracted for Medical Vision Benefits? MEDICAL Do
I need to pre-certify for outpatient procedures? No,
the only time you need to pre certify is if you are being admitted
inpatient into the hospital or other inpatient healthcare facility.
HealthLink
pre-certifies patients, the Fund is responsible for benefits allowed and
paid. What
is the medical deductible? The
medical deductible for Schedule of Benefits I is $300 per individual and
$900 per family. The medical deductible for Schedule of Benefits IV is $750 per individual and $2,250 per family. What
are maximum out-of-pocket expenses? For
Schedule of Benefits I, maximum out-of-pocket (in network) is
$5,000/person or $7,500/person (out of network).
Effective July 1, 2006, there is a cap limit of $10,000 aggregate
per family in network and $15,000 aggregate per family out of network.
For
Schedule of Benefits IV, maximum out-of pocket is $7,500/person.
Effective July 1, 2006, there is a cap limit of $15,000 aggregate
per family. What is the lifetime benefit?The lifetime maximum per person under Schedule of Benefits I is $2,000,000. The lifetime maximum per person under Schedule of Benefits IV is $2,000,000 effective July 1, 2006. For emergency room care, am I responsible for a co-pay?Yes, each time you or a family member go to the emergency room, you have a $100 co-pay. This $100 co-pay is not applied toward deductible. The $100 co-pay is waived only if you are admitted to the hospital from the emergency room. Are
routine medical exams covered? Yes,
100% up to $300 per eligible member and eligible dependent per calendar
year. Once maximum met, no
benefit coverage until new calendar year.
Effective
July 1, 2006 the Fund implemented an Expanded Wellness Program that
specifically includes, colonoscopy, mammogram, pap test, PSA and blood
profiles covered at 90%, no deductible.
This benefit is in addition to the $300 routine wellness benefit. What
else is covered under the Wellness Benefit? Well-baby immunizations, school physicals, routine lab work, HPV vaccine, etc.
For
a newborn child, provide the Fund office a copy of the baby’s birth
certificate and fully complete a new enrollment/beneficiary form. For marriage, provide a copy of the marriage certificate and fully complete a new enrollment/beneficiary form. For divorce, provide a copy of your divorce decree (showing who is responsible for dependent(s) health insurance) and complete a new enrollment/beneficiary form. How
long are my dependents covered? Dependent children are covered up to age 19 or if a full-time student up to age 23. Do
I need to notify the Fund each semester that they are continuing as a
full-time student? Yes, a new statement from the attending school is required to keep coverage active. Additionally, breaks between semesters are covered only if dependent enrolls for the following semester. (claims incurred during the summer will not be covered until the following fall schedule is provided; and claims incurred during the winter will not be covered until the spring schedule is provided.) PRESCRIPTION BENEFITS
For retail prescription refills, can I still go to Walgreens?Yes, effective August 1, 2006, the Fund switched prescription vendors from Walgreens (WHI) to MEDCO and you can still get your 30-day prescriptions filled at Walgreens. I submitted a mail-order prescription in July to Walgreens (WHI). Will MEDCO be able to process it?Yes, all WHI client information will be transferred to MEDCO. However, you will be required to submit a mail order form to Medco with your payment initially, but you are not required to get a new prescription. Will
my prescription benefits be the same on this new plan?
All co-pays will be the same for retail and mail-order prescriptions. However, there will no longer be 90-day retail refills directly from the pharmacy. INSURANCE CARDSWill I have one card to present for prescription and medical benefits? No, effective August 1, 2006, you will receive a HealthLink card to present to medical/dental providers and a prescription card from MEDCO for pharmacy. Can I order additional cards for family members? Yes, you can download a temporary card from the Medco website at www.medco.com or contact the Fund office to issue additional cards. DENTAL
What
is the dental deductible? The dental deductible is $100/person ($300 family limit). Preventative exams, cleanings and bitewings are covered at 90% not subject to this deductible and are covered twice a year per person. Are
braces/orthodontics covered under the dental plan? No, this benefit was removed September 2002. Can
I get a pre-estimate on extensive dental work from the Fund? Yes, request your dental provider to submit charges to the Fund office for processing a pre-treat. VISION
Are
routine vision benefits covered? Routine vision benefits are covered directly through Vision Service Plan (VSP). How do I get a refund if I use an out-of-network vision provider? You can submit your claim directly to VSP for a refund. A VSP Out-of-Network Reimbursement Form can be downloaded from www.vsp.com or requested from the Fund office. Are VSP in-network providers also contracted for Medical Vision Benefits? No, the VSP in-network providers are strictly for routine vision benefits. For in-network medical providers, see contracted providers under HealthLink www.Healthlink.com or FirstChoice at www.mymethodist.net or contact the Fund office. |
Home Health & Welfare Fund Retirement Savings (Annuity) Fund Privacy Statement Site Map
