Basic Plan SPD >> Hospital and Medical Benefits

• Overview of Eligible Expenses
• About the MagnaCare Networks
• In-Network Benefits
• When You Go Out-of-Network
• Coverage When You Are Away from Home
• Benefit Maximums
• Conditions for Hospital and Medical Expense Reimbursement
• Pre-Certification
• Covered Services  
• Excluded Hospital And Medical Expenses

What Benefits Are Provided

The Fund provides a comprehensive program of benefits, including hospital and medical, prescription drug, behavioral health, dental, vision, life insurance, accidental death and dismemberment and pensioner death benefits (only to pensioners from the Building Service 32BJ Pension Fund). Each of these benefits is described in the sections that follow.

Overview of Eligibile Expenses

About the UnitedHealthcare (UHC) Networks

The Plan provides hospital and medical benefits through UHC. This network includes over 106,000 doctors and other participating provider locations and 234 hospitals in the metropolitan area.

UHC ID Card. This card gives you access to thousands of doctors, surgeons, hospitals and other health care facilities in the network. It also gives you 24-hour phone access to a registered nurse who can help you with your health care decisions.

NurseLine. For immediate medical advice, call the NursLine. This is free round-the-clock information. When you call, you can either speak to a registered nurse or select from over 1,100 audiotaped messages in English or Spanish on a wide variety of topics. You may find it helpful to speak to a registered nurse when you need help assessing symptoms, deciding whether a trip to the emergency room is necessary or understanding a medical condition, procedure, prescription or diagnosis. You can reach the NurseLine at 1-866-271-7425.

In-Network Benefits

      You must use network providers. If you do so, there are no deductibles to pay, and no claims to file or track.

      For some specialized treatments, UnitedHealthcare has developed a program for identifying those network providers (hospitals and doctors) that meet specific quality levels based on national guidelines for care. These specific doctors and hospitals have earned a “Two Star” premium designation in the UnitedHealthcare network (UHC). All providers in the UHC network are regularly reviewed to determine if they can maintain their “Two Star” designation or they can earn a “Two Star” designation if they did not have one before. Physicians and facilities are evaluated on two levels – quality and efficiency of care. For details on the UnitedHealth Premium Program, including how to locate a UnitedHealth Premium physician or facility, log onto www.myuhc.com or call the toll free number on your ID card. In addition to knowing that these network providers are performing according to recognized national guidelines and evidence-based standards, effective January 1, 2009, you can reduce your copayment for services when using a “Two Star” network doctor or hospital for specific services. Please see the Schedule of Covered Services to identify those services where your copayment can be reduced or eliminated when using a “Two Star” doctor.

     In-network benefits apply only to services and supplies that are both covered by the Plan and provided or authorized by a network provider. The network provider will assess your medical needs and advise you on appropriate care, as well as take care of any necessary tests, pre-certifications or hospital admissions. When you use a doctor, hospital or other provider in-network, the Plan generally pays 100% for most charges, including hospitalization. You will not have to satisfy a deductible — you will pay a co-payment for most services.

When You Go Out-of-Network

Your Plan does not cover any out-of-network expenses.

Coverage When You Are Away from Home

When you are outside of the  network area, emergency treatment will be considered in-network. No other services will be covered.

Benefit Maximums

There is an annual limit of $200,000, and a lifetime limit of $2,500,000 on hospital and medical benefits payable for each covered person. The annual maximum is the most the Plan will pay for benefits during the year. The lifetime maximum is the most the Plan will pay for benefits during the entire period of time you are enrolled in this Plan or any other medical plan offered by the Fund. There are also limits on how much (and how often) the Plan will pay for certain expenses, even when they are covered. If there are limits on a particular expense, those limits will be indicated under “Covered Services.”

Conditions for Hospital and Medical Expense Reimbursement

• Charges must be for covered health services. The Plan will pay benefits only for services, supplies and equipment that the Plan considers to be covered health services.

• Charges must be less than or equal to the allowed amount. The Plan will pay benefits only up to the allowed amount.

• Charges must be incurred while the patient is covered. The Plan will not reimburse any expenses incurred by a person while the person is not covered under the Plan.

Pre-Certification

Your network provider will do the pre-notification for you. However, it is your responsibility to verify that the provider has obtained the required pre-notification.

Pre-Certification for Medical/Hospital

The following services must be Notified. This pre-notification is done through your network provider.

Call 1-800-245-6051
24 hours a day, seven days a week.

Type of Care	When You Must Call
Outpatient: Dental surgery due to accidental injury to teeth Reconstructive procedures 20 Home health care and home infusion therapy Chiropractic procedures Dialysis Durable medical equipment (rental or purchase over $1,000)	As soon as possible before you receive care
Inpatient: • Scheduled hospital admissions including transplant services • Admissions to skilled nursing or rehabilitation facilities	Five business days before you receive care or as soon as care is scheduled
Emergency Hospital admissions	Within 48 hours after admission
• Maternity admissions lasting longer than two days (or four days for cesarean delivery) •Ongoing hospitalization	As soon as you know care is lasting longer than originally planned
• Admissions to hospice facilities	As soon as possible after receiving care or being admitted

How pre-notification works. UHC's Medical Management professionals will review the proposed care to certify the length of stay and will approve or deny coverage for the procedure based on medical necessity. They will then send you a written statement of approval or denial within three business days after they have received all necessary information. In urgent care situations, they will make a decision within 72 hours after they have received all necessary information(for more information, see Section II).

Covered Services

The following tables show different types of health care expenses and how they are covered.

    In the Hospital1 and Outpatient Treatment Centers*

Benefit
		What You Pay		Then The Plan Pays
Semi-private room and board (for obstetrical care, hospital stays are covered for at least 48 hours following normal delivery, or at least 96 hours following cesarean section)*,**		$250 for an admission or $100 for a maternity admission		100%
In-hospital services of licensed doctors and surgeons(1), (18)		$0		100%
Outpatient2 (18) surgery and care related to surgery (including operating and recovery rooms)		$100		100%
Anesthesia and oxygen		$0		100%
Blood and blood transfusions		$0		100%
Cardiac Care Unit (CCU) and Intensive Care Unit (ICU)		$0 (if $250 co-pay paid for admission already satisfied)		100%
Chemotherapy and radiation therapy		$0		100%
Kidney dialysis3		$0		100%
Pre-surgical testing		$0		100%
Special diet and nutritional services while in the hospital		$0		100%
Skilled nursing care facility4* Benefits are payable for up to 10 days for sub-acute care		$0		100%
Hospice care facility5* Benefits are payable for up to 180 days per lifetime		$0		100%
* Pre-notification required. See footnotes 1 – 5 and 18 in the "Footnotes" section.   ** Effective January 1, 2009: $0 co-payment for cardiac, total joint replacement and spinal surgery at a “Two Star” hospital. $20 co-payment for office visits to a “Two Star” network specialist
Benefit
Home Health Care6
Home health care visits*   Benefits are payable for up to 40 visits per year. This includes infusion and some wound care or to allow early discharge from a facility		$0
Home infusion therapy7 *		$0		100%
Emergency Care
Emergency room8 (no benefit if condition is not emergency)		Plan pays 100% after $100 co-payment ($100 co-payment waived if admitted from emergency room).
Office visits		$20 for primary care $40 for specialist care		100%
Ambulance Services 9		$30		100%

Care in the Doctor's Office

Benefit
		What You Pay		Then The Plan Pays
Office visits		$20 for primary care		100%
Specialist visits**		$40		100%
Chiropractic visits 10 visit maximum per year		$40		100%
Allergy care: Testing only; $1,000 annual benefit maximum		$40		100%
Dermatology care: $1,000 annual benefit maximum		$40		100%
Diagnostic procedures: • X-rays and other imaging • MRIs/MRAs/PETs* • All lab tests		$0 for free-standing facility; $100 for MRI, MRA, CAT if at outpatient hospital		100%
Chemotherapy and radiation therapy		$0		100%
Podiatric care for up to 12 visits per year for diabetic patients or other medically necessary diagnoses; podiatric surgery to $5,000 once every three years*		$20		100%

*Pre-certification required.

** Effective January 1, 2009: $0 co-payment for cardiac, total joint replacement and spinal surgery at a “Two Star” hospital. $20 co-payment for office visits to a “Two Star” network specialist. 

Examples of preventive medical care are listed below and provide a guide of what is considered a covered health service. These guidelines may be modified from time to time based on advancements in medical research. Your physician may recommend additional services based on your family or medical history.

Preventive Medical Care

Benefit
		What You Pay		Then The Plan Pays
Annual physical exam10 including the necessary diagnostic screening tests based on the patient’s age, sex and health risk factors are covered based on current recommendations/guidlines and are modified from time to time based on advancements in the medical research.		$20		100%
Well-woman care      • Mammogram for women age 35–39, one baseline test is covered for women age 40 and older, test covered once per year      • PAP Smear once a year      • Contraceptive devices (IUDs and diaphrams)      • Bone density test age 50 or older, every other year		$0		100%
Well-child care11 (including immunizations) subject to the following frequency limitations - birth to age 1:    7 visits - age1 through age 4:    6 visits - age 5 through age 11:    7 visits - age 12 though age 17:    6 visits - age 18 through age 23:    2 visits		$0		100%

.

See footnotes 10 and 11 in the "Footnotes" section.

Pregnancy and Maternity Care

Benefit
		What You Pay		Then The Plan Pays
Office visits for prenatal and postnatal care from a licensed doctor or certified midwife12, including diagnostic procedures		$20 for 1st visit, then $0		100%
Newborn in-hospital nursery care		$0		100%
Obstetrical care* (in hospital or birthing center)		$100 for an admission		100%
Circumcision of newborn males		$0		100%

Physical, Occupational, Speech or Vision Therapy (including rehabilitation) 13

Benefit
		What You Pay		Then The Plan Pays
Inpatient Services*   Covered only with prior hospital admission, not covered without admission		$0		100%
Office/home*   Benefits are payable for up to 20 visits a year combined for physical, occupational and speech therapy (not covered for outpatient hospital)		$20		100%

Durable Medical Equipment and Supplies14

Benefit
		What You Pay		Then The Plan Pays
Durable medical equipment* (pre-notification required for DME over $1,000 such as wheelchairs and hospital beds)		$30		100%
Prosthetics*		$30		100%

*Pre-certification required.

See footnotes 12-14 and 22 in the "Footnotes" section.

Excluded Hospital and Medical Expenses

The following expenses are not covered under the hospital or medical coverage. However, some of these expenses are covered under your prescription drug or vision coverage. Check the other sections of this booklet to see if an expense not paid under hospital/medical is covered elsewhere under the Plan.

• expenses incurred before the patient’s coverage began or after the patient’s coverage ended

• treatment that does not meet the definition of covered health services

• out-of-network services

• cosmetic treatment15

  - Examples include:

• liposuction or removal of fat deposits considered undesirable, including fat accumulation under the male breast and nipple;

• pharmacological regimens;

• nutritional procedures or treatments;

• tattoo or scar removal or revision procedures (such as salabrasion, chemosurgery and other such skin abrasion procedures);

• hair removal or replacement by any means;

• treatments for skin wrinkles or any treatment to improve the appearance of the skin;

• treatment for spider veins;

• skin abrasion procedures performed as a treatment for acne;

• treatments for hair loss;

• skin abrasion procedures performed as a treatment for acne;

• replacement of an existing breast implant if the earlier breast implant was performed as a cosmetic treatment.

• technology, treatments, procedures, drugs, biological products or medical devices that in UHC's judgment are experimental, investigative, obsolete or ineffective16– also excluded is any hospitalization in connection with experimental or investigational treatments

• expenses for the diagnosis or treatment of infertility

See footnotes 15 and 16 in the "Footnotes" section.

• assisted reproductive technologies including, but not limited to, in-vitro fertilization, artificial insemination, gamete and zygote intrafallopian tube transfer and intracytoplasmic sperm injection

• surgery and/or non-surgical treatment for gender change

• reversal of sterilization

• travel expenses, except as specified

• psychological testing for educational purposes for children or adults

• common first-aid supplies such as adhesive tape, gauze, antiseptics, ace bandages, and surgical appliances that are stock items, such as braces, elastic supports, semi-rigid cervical collars or surgical shoes

• expenses for acupressure, prayer, religious healing including services, and naturopathic, naprapathic, or homeopathic services or supplies

• expenses for memberships in or visits to health clubs, exercise programs, gymnasiums or other physical fitness facilities

• operating room fees for surgery, surgical trays and sterile packs done in a non–state-licensed facility including the doctor’s office. However, a flat fee for surgical trays will be covered when a colonoscopy, andoscopy, or endoscopy is performed in the doctor’s office instead of a hospital.

• orthotics for foot care (including dispensing of surgical shoe(s) and pre- and post-operative X-rays) except as described in footnote 14

• hearing exams

• the following specific preventive care services:
   
  - screening tests done at your place of work at no cost to you
   
  - free screening services offered by a government health department
   
  - tests done by a mobile screening unit, unless a doctor not affiliated with the mobile unit prescribes the tests
   

• the following specific emergency services:
   
  - use of the emergency room to treat routine ailments because you have no regular doctor or because it is late at night (and the need for treatment does not meet the Plan’s definition of emergency)
   
  - use of the emergency room for follow-up visits
   
  - ambulette

See footnote 14 in the "Footnotes" section.

• the following specific maternity care services:
   
  - days in hospital that are not medically necessary (beyond the 48-hour/96-hour stays the Fund is required by law to cover)
   
  - private room (If you use a private room, you pay the difference between the cost for the private room and a semi-private room. The additional cost does not count toward your co-payment.)
   
  - private-duty nursing 

• the following specific inpatient hospital care expenses:
   
  - private-duty nursing
   
  - private room (If you use a private room, you pay the difference between the cost for the private room and a semi-private room. The difference does not count towards your co-payment.
   
  - diagnostic inpatient stays, unless connected with specific symptoms that if not treated on an inpatient basis could result in serious bodily harm or risk to life
   
  - any part of a hospital stay that is primarily custodial
   
  - elective cosmetic surgery15 or any related hospital expenses or treatment of any related complications
   
  - hospital services received in clinic settings that do not meet UHC's definition of a hospital or other covered facility
  

• the following specific outpatient hospital care expenses:
     
  - routine medical care, including (but not limited to) inoculation, vaccination, drug administration or injection, excluding chemotherapy
   
  - collection or storage of your own blood, blood products, semen or bone marrow
  
  - physical medicine or rehabilitation services
  

  - private duty nursing

• the following specific equipment:
   
  - air conditioners or purifiers
   
  - humidifiers or de-humidifiers
   
  - exercise equipment
   
  - swimming pools

See footnote 15 in the "Footnotes" section.

• skilled nursing facility care that primarily:
   
  - gives assistance with daily living activities (including, but not limited, to feeding, dressing, bathing, ostomy care, incontinence care, checking of routine vital signs, transferring and ambulating)
   
  - is for rest or for the aged
   
  - is convalescent care
   
  - is sanitarium-type care, or
   
  - is a rest cure
   

• the following specific home health care services:
   
  - custodial services, including bathing, feeding, changing or other services that do not require skilled care
  

  - that do not seek to cure, or which are provided during periods when the medical condition of the patient who requires the service is not changing

  
  - out-of-network home infusion therapy
   

• the following specific physical, occupational, speech or vision therapy services:
   
  - therapy to maintain or prevent deterioration of the patient’s current physical abilities
   
  - treatment for developmental delay, including speech therapy
   

• the following specific vision care services:
   
  - expenses for surgical correction of refractive error or refractive keratoplasty procedures including, but not limited to, radial keratotomy (RK), photo-refractive keratotomy (PRK) and laser in situ keratomileusis 21 (LASIK) and its variants
   
  - eyeglasses, contact lenses and the examination for their fitting except following cataract surgery (However, see “Vision Care Benefits”, to find out how vision care services may be covered.)
   
  - routine vision care (See “Vision Care Benefits” for coverage information.)
   

• the following services that may be covered elsewhere under the Plan:
   
  - all prescription drugs and over-the-counter drugs, selfadministered injectables, vitamins, vitamin therapy, appetite suppressants, or any other type of medication, unless specifically indicated (However, see “Prescription Drug Benefits” to find out how prescription drug expenses may be covered.)

  behavioral health care services, including inpatient and outpatient behavioral care, as well as inpatient and outpatient substance abuse treatment (detoxification and rehabilitation). However, see “Behavioral Health Care Benefits

”, to find out how these expenses are covered.

- services of a nutritionist and nutritional therapy or counseling except as described in footnote 17
 
- oral contraceptives (See “Prescription Drug Benefits” to find out how oral contraceptives may be covered under the prescription drug program.)
 

• the following miscellaneous health care services and expenses:
   
  - services performed in nursing or convalescent homes, institutions primarily for rest or for the aged, rehabilitation facilities (except for physical therapy), spas, sanitariums, or infirmaries at schools, colleges or camps
   
  - injury or sickness that arises out of any occupation or employment for wage or profit for which there is Workers’ Compensation or occupational disease law coverage (for information about subrogation of benefits, see Section II)
   
  - injury or sickness that arises out of any act of war (declared or undeclared) or military service for any country
   
  - injury or sickness that arises out of a criminal act (other than domestic violence) by the covered person, or an intentionally self-inflicted injury that is not the result of mental illness
   
  - expenses for services or supplies for which a covered person receives payment or reimbursement from casualty insurance or as a result of legal action, or expenses for which the covered person has already been reimbursed by another party who was responsible because of negligence or other tort or wrongful act of that party (for information about subrogation of benefits, see Section II)
   
  - expenses reimbursable under the “no-fault” provisions of a state law
   
  - services covered under government programs, except under Medicare, Medicaid or where otherwise noted
   
  - any hospital or medical care received outside of the U.S. that is not emergency care
   
  - government hospital services, except specific services covered under a special agreement between UHC and a government hospital or services in United States Veterans’ Administration or Department of Defense hospitals for conditions not related to military service

  See footnote 17 in the "Footnotes" section

  
  - treatment or care for temporomandibular disorder or temporomandibular joint disorder (TMJ) syndrome
   
  - services such as laboratory, X-ray and imaging, and pharmacy services from a facility in which the referring doctor or his or her immediate family member has a financial interest or relationship
   
  - services given by an unlicensed provider or performed outside the scope of the provider’s license
   
  - charges for services a relative provides
   
  - charges that exceed the maximum allowed amount for that service or supply or the annual or lifetime maximum
   
  - services performed at home, except for those services specifically noted in this booklet as covered either at home or in an emergency
   
  - services usually given without charge, even if charges are billed
  

  - enteral feedings and other nutritional and electrolyte formulas, including infant formula and donor breast milk, unless they are the sole source of nutrition or unless they are specifically created to treat inborn error of metabolism such as phenylketonuria (PKU) – infant formula available over-the-counter is always excluded

  - non-surgical treatment of obesity

  - surgical treatment of obesity except as described in footnote 18

  - respite care

  - diagnosis or treatment of, or related to, the teeth, jawbones or gums.

  Examples include:

       - extractions (including wisdom teeth);

       - restoration and replacement of teeth;

       - medical or surgical treatments of dental conditions; and

       - services to improve dental clinical outcomes.

  - dental implants. bone grafts, and other implant-related procedures

  - These exclusions do not apply to accident-related dental services for which benefits are provided as described in footnote 19

  See footnotes 18-19 in the "Footnotes" section

  - transplants that are not performed at a designated facility (this exclusion does not apply to cornea transplants) as described in footnote 21

  - mechanical or animal organ transplants, except services related to the implant or removal of a circulatory assist device (a device that supports the heart while the patient waits for a suitable donor heart to become available)

  - donor costs for organ or tissue transplantation to another person (these costs may be payable through the recipient’s benefit plan)

  - purchase cost and associated fitting and testing charges for hearing aids, Bone Anchor Hearing Aids, (BAHA) and all other hearing assistive devices

  - biofeedback

  - medical and surgical treatment of snoring, except when provided as part of a treatment for documented obstructive sleep apnea (a sleep disorder in which a person regularly stops breathing for 10 seconds or longer)

  - a procedure or surgery to remove fatty tissue such as panniculectomy, abdominoplasty, thighplasty, brachioplasty or mastopexy

  - chelation therapy, except to treat heavy metal poisoning

  - medical and surgical treatment of hyperhidrosis (excessive sweating)

  - treatment of benign gynecomastia (abnormal breast enlargement in males)

  - services for which:

       - the person is not legally obligated to pay

       - no charge is made to the person

       - no charge would have been made to the person in the absence of coverage

  - services performed by hospital or institutional staff that are billed separately from other hospital or institutional services, except as otherwise specified in this booklet

See footnote 21 in the "Footnotes" section