|
|
| Effective January 1, 2008 - Coordination of Open Access Medical Benefits & Out-of-Pocket Annual Maximum |
| |
Effective January 1, 2008, Part VII Open Access Medicare, sections 7.1.1 and 7.1.2, are amended to provide that when this Plan is secondary it will coordinate with Medicare as follows:
7.1.1 Medical Benefits Payable
Except as specifically indicated in Section 9.7, if you or your Dependents are entitled to be covered by Medicare, the benefits payable for covered charges under this Plan will be calculated as follows: After Medicare calculates and pays its allowable amount the Plan will pay 80% of remaining Medicare allowable amount. In addition, the 20% of remaining Medicare allowable amount paid by any individual retiree or dependent will be subject to an annual out-of-pocket cap of $5,000. The Plan only pays if the benefits are covered charges under the Plan.
Any difference between Medicare’s allowed amount and the combined amount paid by Medicare and the Fund is your responsibility. Medicare retirees are not required to use HealthLink providers.
Example: Medicare allowable expenses for a hospital visit are $10,000 and Medicare pays $7,000 of that amount. This Plan will pay 80% of the remaining $3,000 ($2,400) and the individual will be responsible for 20% ($600). If the individual reaches $5,000 in out-of-pocket expenses in a calendar year the Plan will pay 100% of the Medicare allowable amount not paid by Medicare for the remainder of the year.
7.1.2 Mental Illness and Chemical Dependency Benefits
Benefits for the treatment of mental illness and chemical dependency for Medicare Retirees and Dependents are the same as for Participants in the Open Access III plan, as described in Section 4.3.5 beginning on page 81, except that Medicare Retirees and Dependents are not required to use participating HealthLink providers to get benefits. For referrals, please contact the EAP at (314) 845-8302. Benefits will be coordinated with Medicare as set out in section 7.1.1 above for all expenses otherwise covered by the Plan. No benefits will be paid if the expense is not covered by the Plan. For example, no further treatment will be covered for chemical dependency unless the patient completes all follow up programs recommended by the Fund’s EAP (i.e., aftercare).
In all other respects the Open Access Medicare Benefits and medical Coordination of Benefit Rules remain the same.
|
| Back to Plan Updates |
|
| |
St. Louis Graphic Arts Joint Health & Welfare Fund
14323 South Outer Forty Rd. - Suite S106
Chesterfield, Missouri 63017 |
Fund Office: (314) 878-1579
twesthues@slgahw.org
Fax: (314) 275-2640 |
| |
If you have any comments about this web site, please contact us at twesthues@slgahw.org. |
| |
Site Concept and Design ©2002 jWeb. Maintenance and Hosting provided by jWeb. |
|
|
|
