Trust Medical Plan - Harrison Electrical Workers Trust Fund

Trust Medical Plan

The Active Employee Plan makes the Trust Medical Plan available to you as an option for medical coverage. If you select this option you will receive your prescription drug benefits through Kroger Prescription Plans and your vision benefits from VSP. You have the option of receiving dental benefits through Kaiser Permanente OR through the Trust Dental Plan.

The cost of coverage through the Trust Medical Plan may be different than similar coverage through the other options offered in the Active Employee Plan. See Plan Options & Rates for the current cost of coverage.

Medical Plan Features
-
Plan Features	In-Network	Out-of-Network
How the Plan works	To receive the highest level of coverage, services must be delivered by in-network (PPO) providers.	You can receive services from out-of-network providers--but the plan pays higher benefits when you go to in-network providers. If there are fewer than 2 preferred provider primary care physicians within a 30 mile radius of your primary residence, medical benefits will be paid at 80% of reasonable and customary covered charges.
Annual Deductible	$250: Individual $750: Family	$250: Individual $750: Family
Annual out-of-pocket maximum Please note: Maximums shown exclude deductibles	Individual: $2,000 Family: $6,000	Individual: $2,000 Family: $6,000
Maximum lifetime benefit	$2,000,000
Most covered services paid at...	The Plan will pay 70% (80% for Preferred Providers) of covered charges until the out-of-pocket maximum is reached, at which time the Plan will pay 100% of covered charges for the rest of the calendar year.
Pre-Certification	The plan offers pre-certification for all inpatient admissions as specified in the Plan booklet. Please see Utilization Review for more information.
Pre-existing conditions limitation	New employees and their dependents are subject to certain preexisting condition limitations. See Exclusions & Limitations and the Plan Booklet for details.

Comparison of Covered Services - Physician and Outpatient Services
Physician and Outpatient Services
Covered Services	In-Network	Out-of-Network
Office Visits	80% after deductible	70% after deductible
Periodic Health Exams	See covered preventative care in Wellness for more information.	See covered preventative care in Wellness for more information.
X-Ray and Lab Services	80% after deductible	70% after deductible
Outpatient Surgery - Physician and Facility	80% after deductible	70% after deductible
Anethesiology-Outpatient	80% after deductible	70% after deductible
Maternity Care All medically necessary care for pregnancy and delivery is covered in the same manner as any other condition requiring medical or surgical care. Maternity care expenses are not available for your pregnant child even if the child is covered by the plan. See your plan booklet for details.	80% after deductible	70% after deductible
Immunizations	80% after deductible	70% after deductible
Allergy Infections	80% after deductible	70% after deductible
Urgent Care Center Services for immediate care when your physician is not available, or after normal office hours.	80% after deductible	70% after deductible
Outpatient Rehabilitation Physical, occupational, and speech therapy. Limit of 30 visits per calendar year. (Up to 60 visits per calendar year for head and spinal cord injuries.)	80% after deductible	70% after deductible

Comparison of Covered Services - Hospitals and Inpatient Services

Hospital and Inpatient Services
Covered Services	In-Network	Out-of-Network
Emergency Room	80% after deductible	70% after deductible
Room and Board	80% after deductible	70% after deductible
Physician Hospital Visit	80% after deductible	70% after deductible
Surgical Services	80% after deductible	70% after deductible
Anesthesiology Fees	80% after deductible	70% after deductible
X-Ray and Lab Services	80% after deductible	70% after deductible
Imaging and Invasive Diagnostic Procedures (MRI, CT Scan etc.)	80% after deductible	70% after deductible
Outpatient Pre-admission Testing	80% after deductible	70% after deductible
Rehabilitative Therapy	80% after deductible	70% after deductible
Organ Transplants	80% after deductible	70% after deductible

Comparison of Covered Services - Other Services

Covered Services	In-Network	Out-of-Network
Ambulance	80% after deductible	70% after deductible
Chemical Dependency	See Chemical Dependency and refer to your Plan booklet for details.	See Chemical Dependency and refer to your Plan booklet for details.
Chemotherapy	80% after deductible	70% after deductible
Chiropractic Services	80% after deductible up to 26 visits per calendar year, including visits to meet your deductible.	70% after deductible up to 26 visits per calendar year, including visits to meet your deductible.
Diabetes Education (One treatment per lifetime)	80% after deductible	70% after deductible
Dialysis	80% after deductible	70% after deductible
Durable Medical Equipment and Supplies	80% after deductible	70% after deductible
Hearing Exams	80% after deductible	70% after deductible
Hearing Aid Devices	Hearing aid devices are not subject to the deductible. The first $400 is paid at 100% with the remaining paid at 50%, up to a maximum benefit of $3,400. This benefit renews every 36 months. (Benefits are not paid for batteries or ancillary equipment not obtained upon purchase of the hearing aid device, nor are charges for repairs, servicing or alteration of a hearing aid device.)
Home Health Care	80% after deductible up to 100 visits per calendar year	70% after deductible up to 100 visits per calendar year
Home Maker Services	80% of amount charged to a maximum of $100 per week
Hospice Care	Plan pays up to a lifetime maximum of $5,000. See Plan booklet for more information on coverage and exclusions.
Inpatient Custodial Care	100% of amount charged to a maximum of $100 per day for the first 20 days of confinement and $78.50 per day for an additional 80 days. The lifetime maximum is $8,280. To be eligible you must formally apply to the Plan Administrator and demonstrate both cause and need. These benefits are not payable if the provider is eligible under the skilled nursing provision of the plan and the services must be provided by a state licensed inpatient care facility.
Mental Health (New employees are subject to a preexisting condition limitation. See the Plan booklet for more information.)	80% after deductible	70% after deductible
Podiatry Services	80% after deductible	70% after deductible
Skilled Nursing Facility	80% after deductible	70% after deductible
TMJ Services	Charges for necessary care and treatment of TMJ and associated myofacial pain are limited to a maximum benefit of $3,000 Lifetime Outpatient care and $10,000 Lifetime for Surgeons' charges for surgical care. Hospital charges associated with surgical care are payable as any other illness.