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Health Fund
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Index

A
Accidental Death and Dismemberment (AD&D) Plan, 98-100

  eligibility, 5, 16, 17
benefits, 98-100
converting coverage, 100
requesting benefits, 100

Active participants, 21

  coordination of benefits, 51-55
eligibility, 5, 16, 17


Acupuncture/acupressure, 9, 62, 74, 124

Administrative information, 101-123

  Claims and appeals rules, 105-108
ERISA rights, 104-105
general plan information, 101-102
HIPAA rights, 113-118
overpayments, 120
plan termination, 120-121
reimbursement and subrogation, 118-120

Air bag benefit, 100

Alternative therapies, 62

Ambulance transfers, 9, 65, 77

Assignment of benefits, 50

B
Birthing Centers, 63, 124

C
Case management, 10, 47, 64-68

Certified Retirees, 7, 29, 12

  coordination of benefits, 54
dependent coverage premiums, 6, 21, 25, 55, 122
Eligibility, 29
Medicare Part A & B, 30
Medicare Part D, 30


Children

  court orders and children's coverage, 27, 52
coverage by more than one plan, 52-54
dependent, 21, 123
of Same-Sex partners, 21-22, 31


Claim-filing process

  dental, 86
medical, 86 , 105
vision 86


Claims and appeals, 105-108

  denial notices, 106
denied claims, 106-108
disability claims, 112
filing claims, 49
other claims, 112


COBRA continuation coverage, 35-38

  coordination with Medicare, 37, 54
coverage options, 38
eligibility, 36
end of coverage, 38
Low Option Plan, 33-35
qualifying events, 36-37


Coinsurance, 125

Contact information, Summary Of Benefits, 16

Contact lenses or eyeglasses, 63

Contraception, 63, 72, 76, 125

Coordination of Benefits (COB), 51-54

  active participants, 51-52
Certified Retirees, 54
COBRA participants, 55


Copayments, 41, 87

Court orders and children's coverage, 27, 52

D
Deductibles, dental, 79

Deductibles, medical, 40

DeltaCare Dental HMO, (DHMO),

  copays, 87
dental providers, 88
emergency care, 88
expenses, eligible, 89-92. See also Expenses,
eligible DPO
expenses, ineligible, 92-93
filing claims, 86
plan limitations, 83-84
predetermination of benefits, 81-82
reasonable and customary limits, 79


Dependent coverage premium, 6, 21, 25, 55, 122

Dependents

 

adding, 23-24
definition of, 21, 57, 71
dependent coverage premium, 6, 21, 25, 55, 122
enrollment of, 24
life events, 27


Disability

  benefits, 34, 37, 112
claims, 112
extension of coverage, 34


Domestic partners, same-sex, 22-23, 130

Drugs. See Prescription drugs; Mental Health and
Chemical Dependency


Durable medical equipment, 66, 126

E
Earnings and coverage eligibility, 7, 17-20

Eligibility, 17-39

  active participants, 7, 21
Certified Retirees, 29
dependent children, 16, 21, 25, 37, 53
eligible dependents, 21, 24-25
granted in error, 20
loss of, 28
Same-Sex Domestic Partners, 22-23, 130
same-sex spouse, 22-23, 130
spouses, 21

Eligible dependents, 21, 51

Emergency dental care, 88, 73

Emergency medical care, 48, 63, 65

Emergency prescription refills, 43

Employee Retirement Income Security Act of 1974 (ERISA), 104-105

Employer contributions, 20

End of coverage, 8, 98

Enrollment for benefits, 8

Excess Earnings Extension (individual writer & bona fide two-person writing teams) 33

Expenses, eligible DHMO 89-92

  bridges, 90
crowns, 90
dentures, 90
diagnostic, 89
endodontic, 90
general services, 91
oral surgery, 90
orthodontic, 91
periodontic, 90
preventive, 89
restorative, 89


Expenses, eligible DPO, 89-92

  basic, 82
cast restoration, 82
crowns, 82
diagnostic, 80
implants, 83
inlays, 82
jackets, 82
onlays, 82
orthodontic, 80
preventive, 78
prosthodontic, 80


Expenses, eligible medical, 62-74

  acupuncture/acupressure, 62, 62, 74, 124
ambulance transfers, 65
Starting on page 98 contact lenses or eyeglasses, 63
durable medical equipment, 66, 126
elective surgery, 63
electro convulsive therapy (ECT), 9, 62
enhanced external counterpulsation therapy (EECT), 64
home health care, 64
home infusion therapy, 64
hospice care, 64
hospital, surgical, medical, 65-66
inversion device, 66
mastectomy benefit, 73
mental health and substance abuse, 96
physical and occupational therapy, 9, 62, 129
skilled nursing facility, 73
speech therapy, 73
temporomandibular joint dysfunction (TMJ), 74
transplants, organ and tissue, 67
wellness benefit, 74
wigs, 74

Expenses, ineligible DHMO, 92-93

Expenses, ineligible DPO, 84-85

Expenses, ineligible medical, 74-77

Explanation of Benefit (EOB) form, 51

Extended Coverage Program, 31

  for individual writers, 15
Low Option Plan, 46-48


Extensions of coverage, 31-34

  active survivor coverage, 35
Certified Retiree survivor coverage, 35
total disability, 16
External Review Procedures, 110-111


Eyeglasses or contact lenses, 63

F
Foreign country, treatment in, 50

Frequently asked questions, 122-123

G
General plan information, 101-102

  Administrator 101
Trustees, 103


Generic drugs, 56-57

Glossary, 124-131

H
Health Insurance Portability and Accountability Act (HIPAA), 113-118

Home infusion care, 64

Hospice care, 64

Hospital

  admission, 41
benefits, 65-66


I

Inversion device, 64

L
Life Insurance Plan, 7, 98-100

  benefits, 98-100
converting coverage, 99
eligibility, 98
if you become disabled, 98
if you retire, 29
requesting benefits, 99


Lifetime maximum benefit, 42

Low Option Plan, 46-47

  coordination of benefits, 51
denied claims, 106-108
emergency care, 48
expenses, eligible, 53-58. See also Expenses,
eligible medical
expenses, ineligible, 59-61
filing claims, 49-50
provider directory, 16
urgent care, 48


M

Mail-order service, 57-58

Mastectomy benefit, 73

Medical emergency, 48

  assignment, 54 sidebar
coordination with COBRA, 37
Part A and B, 30
Part D, 30

Mental Health and Chemical Dependency, 96

N
Newborn's and Mother's Health Protection Act (federal law), 94

O
Oral surgery, 78

Organ and tissue transplants, 67

Orthodontic care, 83, 91

Out-of-pocket maximum, 42

Overpayments, 120

P
Periodontic benefits, 90

Pharmacies, 55-57

Physical and occupational therapy, 53, 54, 55

Preauthorization, 67-68

Pre-existing condition, 7

PPO Plan 51-54

  coordination of benefits, 38
coverage for non-network providers at network facilities, 35
denied claims, 87
emergency care, 36
expenses, eligible, 53-58. See also Expenses,
eligible medical
expenses, ineligible, 59-61
filing claims, 37
network vs. non-network, 26-28
provider directory, 26
urgent care, 36


Pregnancy, complications of, 98

Prescription drugs, 55-60

  cost, 55-58
Dispense as Written (DAW), 56
eligibility, 55
generic, 56
mail-order service, 57-58
non-preferred brand, 56
preferred brand, 56
refills, 56 sidebar, 57-58
retail purchase, 58-59


Preventive Care Services 69-72

Primary Care Dentist(PCD), 87-88

Prosthodontics, 78, 83-84

Q
Qualified Medical Child Support Orders (QMCSOs), 94

Qualifying events, COBRA, 36-37

R
Reasonable and customary (R&C) limits

  dental (DPO), 79, 130
medical, 41, 130

 

Reimbursement and subrogation, 118-120

Retail prescriptions, 56

Retirees, Certified, 6-7

  coordination of benefits, 54
dependent coverage premiums, 6
eligibility, 29
Medicare Part B, 30


S

Same-sex domestic partners, 22-23

Same-Sex Spouse, 22-23

Seat belt benefit, 100

Skilled nursing facilities (SNF), 73

Speech therapy, 73

Summary of Benefits, 6-16

Surgical benefits, 73

T
Termination of coverage, 20, 120

The Industry Health Network (TIHN), 45

Therapy

  alternative therapies, 62
covered providers, 62
electro convulsive (ECT), 62
enhanced external counterpulsation (EECP), 64
home infusion care, 64
speech therapy, 73

Transplants, organ and tissue, 67

Trustees of health plans, 103

U
Urgent care, 48


V

Vision benefits, 61

  cost, 61
eligibility, 61
expenses, covered, 61
expenses, not covered, 61
filing claims, 49

W
Wellness benefit, 74

Wigs, 74

Writer's Point System, 31