| General Covered Medical Benefits | Coverage (100% up to Funds fee allowance, after applicable Copayment) **Copayment amounts vary per plan. See Copayment schedule for your plan’s copayment amounts |
|---|---|
| Inpatient Hospital, including semi-private room, intensive or coronary care unit, renal dialysis, mental illness, alcohol/chemical dependency and maternity. | Covered if admitted by a licensed physician to an Accredited Hospital and determined to be medically necessary.
Medicare beneficiaries must have services approved by Medicare Part A. Medicare Part A is the primary payer. Non-Medicare beneficiaries must have services approved by the Funds’ Precertification Department at 1-800-292-2288. |
| Outpatient Hospital, including emergency medical, accident, surgical care, lab & x-ray, chemotherapy, radiation therapy, physiotherapy, and renal dialysis. | Covered if medically necessary.
Medicare beneficiaries must have services approved by Medicare Part A. Medicare Part A is the primary payer. |
| Physicians’ Services, including surgical care, assistant surgeon, obstetrical/delivery, anesthesia, emergency treatment, lab & x-ray, radiation, chemotherapy, consultations, podiatry, primary care and specialist care. | Covered if medically necessary. |
| Skilled Nursing Care Facility | Covered if admitted by a licensed physician to a licensed skilled nursing care facility and is medically necessary.
Custodial/non-skilled care is not covered (i.e. bathing, housework, day care) Must be a Medicare approved Skilled Nursing Facility and must have a qualifying hospital stay prior to admission. Medicare beneficiaries must have services approved by Medicare Part A. Medicare Part A is the primary payer for the first 100 days. The Funds will pay the Part A coinsurance during that time. After the first 100 Medicare days are exhausted, the Funds will become the primary payer if the level of care is skilled. Precertification is required for days in excess of the 100 day maximum. Non-Medicare beneficiaries must have services approved by the Funds Precertification Department at 1-800-292-2288. |
| Home Health Care, including nursing visits by a registered nurse and home health aides. | Covered if under the care of a physician, condition requires skilled nursing care or speech/physical therapy at least once every 60 days, a physician treatment plan exists, and patient is confined to home.
Requires approval by the Funds’ Precertification Department at 1-800-292-2288. Medicare beneficiaries – Medicare Part A is the primary payer. |
| Physical (PT) and Speech Therapy (ST) | Covered when prescribed by a physician to restore functions lost or reduced by illness or injury. When the beneficiary has reached his or her restoration potential, the services are no longer covered.
Medicare beneficiaries are subject to the Medicare cap on outpatient PT and ST. Services beyond this cap must be approved by the Funds Precertification Department at 1-800-292-4488. Non-Medicare beneficiaries must have services approved by the Funds’ Precertification Department at 1-800-292-2288. |
| Durable Medical Equipment (DME) and Supplies | Covered for rental or, where appropriate, purchase when determined to be medically necessary by a physician.
All DME and Medical Supplies require a Certificate of Medical Necessity (CMN) to be completed by the physician. All beneficiaries are required to use one of the seven Funds Network DME vendors. Provider must obtain precertification for any DME items over $300. Rent-to-cap period of 15 months applies to all rentals. Incontinence supplies, such as adult diapers and chux are covered, limited to 3 boxes per month. Maximum allowable of $150 per month per benefit. |
| Oxygen | Covered when ordered by attending physician, patient is referred to a designated pulmonary consultant for testing and the consultant’s report is submitted to the Plan administrator with the order for oxygen.
The 15 month Rent-to-Cap period applies to all oxygen equipment rentals. Oxygen requires precertification and must be recertified annually. Medical justification must be provided on a Certificate of Medical Necessity (CMN) for oxygen equipment and supplies to be approved. Additional documentation is also required. |
| Prosthetics and Orthopedic Devices | Covered when prescribed by a physician and is medically necessary. |
| Preventive Care | Routine physical examinations are covered for: Newborns and children up to age 6, age 55 and over, existing medical condition and being treated by physician, undergoing annual or semi-annual exam by gynecologist, or undergoing routine exam prescribed by a specialist as part of such specialist’s care of a medical condition.
American Medical Association (AMA) guidelines are utilized for covered visits. If in excess of guidelines, claims will suspend for medical review. Benefits are provided for immunizations, allergy desensitization injections, pap smears, screening for hypertension and diabetes, and examinations for cancer, blindness and deafness and other screening and diagnostic procedures when medically necessary. 1993/Pre-Funded Plans – Age limit does not apply to Medicare eligible beneficiaries. CBF/1992 Plans – Age limit does not apply to any beneficiary. |
| Non-Emergency Transportation | Covered with prior approval from the Plan Administrator if for ambulance transportation to or from a hospital, clinic, medical center, physician’s office or skilled nursing care facility, when considered medically necessary by a physician.
Benefits are available if the medical care is not available near the beneficiary’s home and the beneficiary must be taken out of area, or if the beneficiary requires frequent transportation, such as for radiation or physical therapy. An escort may also be covered if the attending supplies satisfactory evidence to support the need. Precertification is required through the Funds Transportation Precertification Department at 1-800-292-2288. Non emergency ambulance transportation for scheduled trips to receive medical care is provided only for patients that are bed confined or can only be moved by a stretcher to the ambulance. Alternate forms of transportation for scheduled trips (i.e. Ambulette, Van, Taxi, shuttle, or bus) will be approved only if assisted transportation is medically necessary and beneficiary would otherwise require ambulance transportation. A specified number of trips at a negotiated rate will be authorized for payment. Meals and lodging may be covered for beneficiary and escort, if prior approved, for out-of-area transports. |
| Hearing Aids | Services must be provided by an approved hearing aid vendor who has signed a Hearing Aid Vendor agreement and is on the approved list of 29 providers.
Hearing aids over $600 require precertification through the Funds Hearing Aid Precertification Department at 1-800-292-2288. Benefits for necessary repairs and maintenance, except the replacement of batteries, will be provided after the expiration of the warranty period. Benefits will be provided for replacement hearing aids only if a new aid is needed because of a change in the beneficiary’s condition, or the aid no longer functions properly. |
| Chiropractic Care | Medicare beneficiaries have a chiropractic benefit through Medicare. Medicare does not cover spinal manipulation.
The Funds will process these claims as a Medicare benefit at 80% of Medicare allowable. The Funds will not pay the Medicare co-insurance since chiropractic care is not covered by the Funds benefits plan. For Non-Medicare beneficiaries this is not a covered benefit. |
| Routine Vision Care | Covered as a limited benefit. Benefits are provided once every 24 months up to a maximum amount for each service.
See Vision fee schedule for reimbursement amounts. Lenses will not be covered unless the new prescription differs from the most recent one by an axis change of 20 degrees or .50 diopter sphere or cylinder change and the lenses must improve visual acuity by at least one line on the standard chart. |
