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TABLE OF CONTENTS |
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4.0 OPEN ACCESS III MEDICAL BENEFITS FOR EMPLOYEES AND DEPENDENTS |
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IMPORTANT: The benefits described in Part IV and Part V of this Summary Plan Description only apply to those Participants and their Dependents, who have selected the Fund’s Open Access III coverage.
Benefits for Retired Participants enrolled in the Value Plan are described in Part VI. Benefits for Medicare Retirees are described in Part VII. Participants enrolled in the Medicare Complete Plan will have the benefits described in the Evidence of Coverage booklet distributed to them by United HealthCare and not those described in this Summary Plan Description. The HMO benefits that those individuals receive under Medicare Complete will be determined by United HealthCare and not the Trustees of the Fund.
Introduction
The Plan has an arrangement with HealthLink’s Open Access III program. Under this arrangement, benefit levels vary with the type of provider used. The highest benefits are paid when HMO providers are used, while slightly lower benefits are paid for using PPO providers. Benefits are further reduced when Non-Network providers are used.
Although the highest level of benefits in the HealthLink Open Access III program is called “HMO,” it is not a traditional Health Maintenance Organization (HMO). You do not have to select a primary care physician or obtain referrals to see specialists. You do not have to choose to be in the HMO or PPO; you are free to use any provider at any time. Your benefits for each service will be determined based upon the network participation status of the provider (HMO, PPO or Non-Network), with the highest benefits paid when you use HMO providers.
In addition to its contract with HealthLink, the Fund has a contract with USA Managed Care Organization to access its PPO network. You should contact USA listed on your Identification card to find out whether there are any providers in your area. Benefits for these providers will be paid at the PPO benefit level shown below in Section 4.1.
An additional level of benefits is provided for students who reside outside the HealthLink service area (Out of Area). The various benefit levels are described below.
A separate list of participating providers will be provided, however in order to ensure that you receive the HMO or PPO benefits shown below, you should contact the Fund Office at 314-878-1579 or HealthLink at the telephone number listed on your medical identification card to determine whether your Physician, Hospital or other health care provider is a participating member of the network. Participating providers are also listed on the Internet at www.healthlink.com or through a link on the Fund’s website (www.slgahw.org).
HealthLink is also under contract with the Fund to provide Hospital Predetermination Services. This includes:
Voluntary Predetermination (See Section 8.1.1); and
Voluntary Concurrent Review as to length of stay (See Section 8.1.4) |
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TABLE OF CONTENTS |
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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 |
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If you have any comments about this web site, please contact us at twesthues@slgahw.org. |
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