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Health Fund

Managing Your Care

In most health care scenarios, you can take the time to discover the most effective and efficient way to manage your care. The Fund's Utilization Administrator can help facilitate your care through Case Management A program offered by the Fund which provides participants assistance, coordination and management of medical care and treatment. intervention to help you make those non-urgent decisions. In emergency situations, you will need to take immediate action.

Emergency Care

No matter where you are, if you have a medical emergencyA sudden and, at that time, unexpected change in a person’s physical or mental condition which, if not treated immediately, could result in a loss of life or limb, significant impairment of a bodily function or permanent dysfunction of a body part. Examples include heart attack, stroke, severe bleeding, serious burns and poisoning. - that is, a sudden and, at that time, unexpected change in your physical or mental condition which, if not treated immediately, could result in a loss of life or limb, significant impairment of a bodily function or permanent dysfunction of a body part – it is recommended that you go to the nearest emergency room to get the care you need. Here are some examples of medical emergencies.

  • Active labor;
  • Stroke;
  • Complex fractures;
  • Poisoning;
  • Seizure or loss of consciousness;
  • Suspected medication overdose;
  • Severe pain;
  • Severe shortness of breath;
  • Severe burns;
  • Uncontrolled bleeding;
  • Sudden paralysis or slurred speech; and
  • Chest pains or a severe squeezing sensation in the chest.

If you are covered under the PPO Plan or Low Option Plan and incur charges as the result of a medical emergency, your reimbursement level will depend on whether you received care from network or non-network providers. If, as a result of an emergency, you did not have time to contact a network provider, the Fund may review and consider your non-network claim for network benefits, subject to the Reasonable and Customary limits. You are responsible for contacting the Administrative Office to determine if services qualify for network benefits.

Effective January 1, 2012, the Fund will charge you the same copaymentA fixed dollar amount you pay for an eligible expense at the time the service is provided. or coinsurance for hospital emergency room services only, when you obtain those services from a network hospital or from a non-network hospital. Accordingly, emergency care provided in an emergency room by non-network provider will be considered at the network coinsuranceThe percentage of eligible expenses you're responsible for paying. level, or 85% for the PPO Plan and 70% for the Low Option Plan, subject to the Plan's $50 copayment and the annual deductible. However, if you obtain those services from a non-network hospital, that hospital may bill you separately if the hospital's charges exceed the Plan's allowances for the services.

Urgent Care

If you have a situation that is not life-threatening but does require immediate medical care, it's called an urgent conditionA condition that's not as serious as an emergency medical condition but that still requires immediate medical treatment, such as an ear infection, a sprain, a urinary tract infection, a simple bone break (e.g., toe, finger), a minor burn, or back pain. . Here are some examples:

  • Back pain;
  • Ear infections;
  • Minor burns;
  • Simple bone breaks (e.g., toe, finger);
  • Sprains; and
  • Urinary tract infections.

If you're in a PPOAn acronym for Preferred Provider Organization. network area and want to receive the higher, network level of benefits, you must seek urgent care from a network provider; otherwise, you will receive the lower, non-network level of benefits. Emergency room services for Urgent Care do not qualify for the higher network coinsurance.