QUESTION: What is my deductible?

Transcription

1 QUESTION: What is my deductible? ANSWER: The deductible is the dollar amount (shown in the Schedule of Benefits) that you and your eligible Dependents are responsible to pay before the Medical Expense Benefit is payable. Only Covered Charges may be used to satisfy the deductible. The deductible applies only once in a calendar year. If Covered Charges used to satisfy the deductible, in part or in full, are incurred during the last three months of a calendar year, then those charges will be used to satisfy the deductible for the following year as well. After eligible family members have collectively satisfied the family deductible (shown in the Schedule of Benefits) within a calendar year, no further deductible will be required for any family member for the remainder of that calendar year QUESTION: What is Coinsurance? ANSWER: When you reach your deductible, you must pay a percentage of the remaining costs this is the coinsurance amount. On in-network claims, the typical co-insurance is 80%/20%. What this means is that, on allowable expenses, the Plan will pay 80% of the claim s eligible amount and you will be responsible for the remaining 20% after your annual deductible has been met. EXAMPLE: You have a $1,000 hospital bill, and an Annual Deductible of $200 with 20% in-network coinsurance. You pay the $ deductible plus 20% coinsurance. If there were no in-network discounts on the hospital expense, the Fund will pay $640.00, while you pay the $200 deductible plus $ in coinsurance. QUESTION: How does my Out- Of- Pocket Maximum work? ANSWER: The Out-of-Pocket Maximum applies to in-network claims only. The amount each year represents the maximum amount an individual or family will pay either as a percentage of benefits. Please refer to the Schedule of Benefits for specific amounts. After you have reached your Out-Of-Pocket maximum for the year, Central Laborers will begin to pay 100% of the allowed amount on applicable medical expenses. QUESTION: What counts toward my Out-Of-Pocket maximum? ANSWER: Your Out-Of-Pocket maximum does not include your premiums or charges for health care services that Central Laborers does not cover. It also does not include out-of-pocket expenses incurred on Out-of-Network claims. It does include your coinsurance that you must pay toward in-network expenses you incur.

2 QUESTION: What does it mean when my benefits are based on a calendar year? ANSWER: Benefits that are based on a calendar year are calculated from January 1st through December 31st of any given year. If you use all of your benefits in one year, you will be renewed with available benefits to use as of January 1st of the following year. Some examples of benefits that are based on calendar years are as follows: (1) Dental benefits - $1,500 per person each calendar year. (2) Rehabilitation Services (Outpatient) 60 visits each calendar year. (3) Home Health Care 40 visits each calendar year. Note: Consult your Plan Summary Description for other benefits that are based on a calendar year and what restrictions may apply to each. QUESTION: Why do I receive my self-payment notification after I lose eligibility? ANSWER: Central Laborers' must wait until the end of the month to send self-payment notifications so as to allow time for all employers to submit contributions for the hours of work you performed. By waiting, it allows for all hours to be added to your contributions history, possibly eliminating the need for you to self-pay for coverage or, if you must self-pay, possibly reducing the amount you will need to pay in order to maintain coverage. So long as a self-payment is sent to the Fund Office with a post-mark date on or before the designated deadline, eligibility will be reinstated retroactive to the first day of the quarter and any claims incurred will be considered.

3 QUESTION: If I am on a Retiree Plan, what benefits besides medical am I entitled to? ANSWER: The Retiree Plan has medical benefits provided through the BCBS PPO and the HealthLink networks. In addition, Retirees have the following benefits through Central Laborers Welfare Fund: (1) Vision Benefits - $300 per year for the routine exam, routine tests, frames, lenses and/or contact lenses. (2) Hearing Benefits - $75 for hearing examination services every 24 months and $400 to apply toward hearing aids every 60 months. (3) Prescription Benefits through Express-Scripts and specialty medications that are purchased through Accredo mail in service (4) Dental Benefits - $1,500 per eligible participant / dependent per calendar year. (5) Physical Benefits QUESTION: What immunizations do you cover for my children? ANSWER: (SEE LIST BELOW) THE FUND ALLOWS THE FOLLOWING WELL CHILD IMMUNIZATIONS: Diphtheria (DTAP) Pertussis (DTAP) Tetanus (DTAP) Poliomyelitis (POLIO) Measles (MMR) Rubella (MMR) Mumps (MMR)

4 Hepatitis B (HEP B) Chicken Pox/Varicella TB Skin Test Influenza (FLU) Haemophilus influenza type B (HIB) ONLY for dependents under 5 years of age PediaRX Rotavirus Prevnar Pneumoccoal Conjugate Vaccine, 12 Valent (Note Pneumoccal (PPSVS23) is not covered for Dependent Children) QUESTION: Where do I send my claims? ANSWERS: If you are a member of the HealthLink Medical Plan: a. Submit all medical and network vision claims to: HealthLink PO Box St. Louis, MO b. Submit all dental, non-network vision and hearing claims to: Central Laborers Welfare Fund P.O. Box 1267 Jacksonville, IL If you are a member of the Blue Cross / Blue Shield PPO Medical Plan: a. Submit all medical and network vision & hearing claims to: Blue Cross / Blue Shield of Illinois P.O. Box Chicago, IL 60690

5 b. Submit all dental, non-network vision & hearing claims to: Central Laborers Welfare Fund P.O. Box 1267 Jacksonville, IL QUESTION: If I have a question or I need to contact someone regarding claim questions, where do I call? ANSWER: Any questions regarding claim payments can be directed to the Fund Office Customer Service area at All providers should be directed to call one of the numbers listed below if they have questions regarding network discounts that were applied on a specific claim. a. Blue Cross / Blue Shield (800) b. HealthLink (800) QUESTION: If I want to know if a provider participates in my medical plan network, who do I contact? ANSWERS: BlueCross/BlueShield of Illinois or HealthLink or QUESTION: What type of coverage must my spouse take through his/her employer before claims are considered for secondary payment under my Plan? ANSWER: If your spouse works full time and his/her employer offers comparable coverage to this Plan or comprehensive insurance, your spouse must enroll in that coverage before this Plan will coordinate benefits. The following further defines excluded coverage types: "In the event that a participant's spouse has health care coverage available through his or her employment and said health care coverage contains a provision commonly known as a "wrap around" provision, or some other similar provision whose purpose is to provide primary coverage only for a small amount of comprehensive coverage while purporting to defer or transfer the much larger secondary coverage to the other spouse's ERISA Welfare Fund, then in such event, this fund expressly limits said secondary coverage to the same amount or same percentage as contained in the primary coverage set forth in the "wrap around" or similarly provision. If you or your spouse have any questions regarding what is considered a comparable coverage, please contact the Fund Office at for assistance.

6