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TABLE OF CONTENTS |
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A. BENEFITS APPLICABLE TO ACTIVE PARTICIPANTS |
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1. LIFE INSURANCE
A Life Insurance Benefit of $10,000 is paid to the beneficiary of an active Participant who dies from any cause. (See Part II, beginning on page 50, for details).
2. WEEKLY DISABILITY INCOME BENEFITS
Disability income benefits are provided to active Participants who become unable to work due to Injury or Illness. (See Part III, beginning on page 53, for details).
Weekly Benefit Amount
66-2/3% of weekly earnings up to a maximum benefit of $425 per week
Reductions
Benefits are reduced by Social Security and Workers’ Compensation disability benefits, unemployment benefits and by amounts recovered due to third party liability
Benefits Begin
On the fourth working day of disability
Maximum Duration of Benefits
Weekly disability income benefits will be limited to 26 weeks unless you are determined to be unable to work at any substantial gainful occupation. If you continue to meet that requirement, your weekly disability income benefits will continue for up to an additional 26 weeks at a reduced amount of 50% of your regular weekly earnings subject to a maximum benefit of $320 per week, which will be reduced by any Social Security Disability Benefits you receive.
Weekly disability income benefits are limited to a maximum of 52 weeks in any 2-year period for disabilities due to any and all causes.
3. MEDICAL BENEFITS - HEALTHLINK OPEN ACCESS III
Medical benefits are provided to Participants and their Dependents who incur Covered Charges as the result of a non-occupational Injury or Illness.
The Trustees have contracted with HealthLink, Inc. to access its provider networks through the HealthLink Open Access III program for active Participants. Medical benefits are described in detail in Part IV, beginning on page 58.
Open Access III is a three-tiered plan that offers you different benefit levels based upon your choice of provider. When you use “HMO Providers” you will receive the Plan’s highest level of benefits. When you use “PPO Providers,” your benefits may be lower than those for “HMO Providers,” but greater than benefits for providers who do not participate in the HealthLink network (Non-Network). This differential between HMO, PPO and Non-Network reimbursement is intended to encourage you to use HMO or PPO Providers. Because HealthLink’s network has a large number of participating Hospitals and Physicians, there is an excellent selection of HMO and PPO Providers available through the Open Access III program.
The Fund also has an agreement to access USA Managed Care Organization’s PPO network in geographic areas not serviced by HealthLink. Participants using providers in the USA network are entitled to the “PPO” level of benefits. Specific information about the USA PPO can be found on your Identification Card.
| a. Deductible Amounts |
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HMO ProviderPPO Provider |
PPO Provider |
Non-Network Provider |
| Individual |
Family |
Individual |
Family |
Individual |
Family |
| Annual |
$300 |
$600 |
N/A |
N/A |
N/A |
N/A |
| Inpatient |
N/A |
N/A |
$300 |
$600 |
$500 |
N/A |
| Outpatient |
N/A |
N/A |
$400 |
$800 |
$400 |
$800 |
There is a $300 individual and $600 family combined inpatient and outpatient annual deductible when using HMO providers. Any charges applied to your HMO calendar year deductible also count towards the PPO outpatient deductible for that calendar year. You are also responsible for any applicable Co-Pays (see section 4.1, beginning on page 59) for each Physician’s office visit, inpatient hospital confinement and outpatient procedure.
The Non-Network Inpatient Deductible is applied to each inpatient confinement in a Non-Network facility. The PPO Inpatient Deductible and all Outpatient Deductibles are applied once per calendar year.
The PPO Inpatient Deductible rather than the Non-Network Inpatient Deductible applies to Emergency (see definition of “Emergency” on page 119) Non-Network confinements provided that the patient is transferred to an HMO or PPO Hospital as soon as medically possible
| b. Benefits Payable |
| HMO Providers |
PPO Providers |
| 100% |
90%* |
| Non-Network Providers |
| First $5,000 |
50% |
| Next $11,500 |
80% |
| Thereafter |
100% |
*Once the individual or family out-of-pocket maximum is met (see paragraph c on page 12), additional eligible covered charges will be payable at 100%.
Please refer to the Schedule of Benefits in Section 4.1, beginning on page 59, for detailed information on payment for specific services and applicable Co-pay amounts as well as additional benefits payable for Non-Network Emergency and ancillary services.
| c. Out-of-Pocket Maximums |
| With a few exceptions, your out-of-pocket cost per calendar year for deductibles, co-pays and the percentage of covered charges not paid by the Plan is limited as follows: |
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HMO or PPO Provider |
Non-Network Provider |
| Individual Maximum |
$2,000 |
$5,700 |
| Family Maximum |
$4,000 |
$11,400 |
d. Benefits for Dependent Children Living Outside HealthLink’s Service Area
Eligible Dependent children who are attending school in an area not serviced by HealthLink providers will receive the Plan’s PPO benefits when using providers who participate in the USA Managed Care Organization Network. For information on how to identify USA providers, please contact USA Managed Care at (800) USA-3860 or go to their web site at www.usamco.com
If a Dependent child living outside the HealthLink service area uses a Non-Network provider, the following benefits apply:
Out of Area Deductible
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Individual |
Family |
| Inpatient Deductible |
$400 |
$800 |
| Outpatient Deductible |
$400 |
$800 |
Out of Area Benefit Payable
After satisfaction of the deductible amounts for each calendar year, Covered Charges for services performed by Non-Network providers outside the HealthLink service area, are reimbursed as follows:
| Individual |
Family |
| 80% of the first $10,000 |
80% of the first $20,000 |
| 90% of the next $10,000 |
90% of the next $20,000 |
| 100% thereafter |
100% thereafter |
Covered charges for services performed by providers who participate in the USA PPO network, will be reimbursed at the same level as HealthLink PPO providers (90% until the out-of-pocket maximum is met and 100% thereafter).
Out of Area Out-of-Pocket Maximum
With a few exceptions, when using Non-Network providers outside the HealthLink service area your out-of-pocket cost per calendar year for deductible and the percentage of covered charges not paid by the Plan is limited as follows:
| Individual |
Family |
| $3,800 |
$7,600 |
e. Open Access III Mental Illness and Chemical Dependency Benefits
Benefits for these conditions are different than the Plan’s benefits for other Illnesses, however charges are subject to the same Inpatient and Outpatient Deductible amounts. These benefits apply to all Covered Persons under the HealthLink Open Access III Plan.
To receive the highest possible benefits, before you begin treatment for any Mental Illness or Chemical Dependency you should contact H & H Health Associates at (314) 845-8302 to obtain a referral and use HealthLink Providers. Please see Section 4.3.5, beginning on page 81, for details on Mental Illness and Chemical Dependency benefits and limitations.
i. Mental Illness and Chemical Dependency Benefits Payable
Hospital and Outpatient Treatment Program Charges at HealthLink Hospitals
Medically Necessary charges incurred at HealthLink hospitals are paid at 80% if you have received a referral for such care. Medically Necessary charges at HealthLink hospitals without a referral are paid at 60%. If it is determined that only a portion of your care was Medically Necessary then the Plan will pay the applicable percentage of the Medically Necessary portion of your care but none of the non-medically necessary portion.
Physician Charges (up to a maximum charge of $100 per visit)
| If Referred by EAP |
70% |
| If not Referred by EAP |
50% |
Licensed Clinical Psychologist, Licensed Professional Counselor and Licensed Clinical Social Worker Charges (up to a maximum charge of $80 per visit)
| If Referred by EAP |
70% |
| If not Referred by EAP |
Not Covered |
No payment will be made on Physician’s charges over $100 per visit or other mental health and Chemical Dependency provider’s charges over $80 per visit.
If you use a Non-Network Hospital (regardless of the reason), the Plan pays 50% of the covered charges after satisfaction of the Inpatient or Outpatient Deductible for Medically Necessary care.
ii. Mental Illness and Chemical Dependency Benefit Maximums and Limitations
Lifetime Maximums
| Chemical Dependency |
$50,000 per person |
Mental Illness and Chemical Dependency Combined - 75 days of inpatient hospitalization (including days prior to April 1, 1998). Two days of partial or day hospitalization are considered one inpatient day.
Calendar Year Maximums
| Chemical Dependency |
$10,000 per person |
| Physician Services for Chemical Dependency |
$2,000 per person |
Mental Illness and Chemical Dependency Combined - 30 days of inpatient hospitalization (two days of partial or day hospitalization are considered one inpatient day).
Chemical Dependency Limitation
No further treatment covered unless patient completes all follow-up programs recommended by the Fund’s EAP (i.e., aftercare).
4. PRESCRIPTION DRUG BENEFITS - OPEN ACCESS III
After the Participant pays the Co pay set out below, the Plan pays 100% of the cost of prescription drugs up to a 30-day supply when purchased from Express Scripts participating pharmacies and up to a 90-day supply of maintenance drugs.
Co-Pays
| Each Generic prescription or refill |
| Co-pay |
20% |
| Minimum Co-pay |
$5 for up to and including a 30-day supply;
$15 for over a 30-day supply |
| Each Brand Name prescription or refill |
| Co-pay |
35% |
| Maximum Co-pay |
$50 for up to and including a 30-day supply;
$150 for over a 30-day supply of certain catastrophic single source brand name drugs |
| Prescription Drug Out-of-Pocket Maximum per Calendar Year |
| Per individual |
$1,500 |
| Per family |
$2,500 |
You should refer to Part V beginning on page 88 for a complete description of the Plan’s prescription drug benefits, including covered and excluded drugs and additional limitations.
5. DENTAL BENEFITS
a. Dental Deductible
| Calendar Year Deductible Per Person: |
$50 |
The calendar year deductible applies to services listed under Coverages B and C in Section 14.3 on pages 135-136.
| Coverage A: |
80% |
| Coverages B and C: |
50% |
For details on what services are covered under each coverage category (A, B and C) as well as dental benefit exclusions and limitations, please refer to Part XIV, which begins on page 134.
6. COORDINATION WITH OTHER BENEFITS
Medical benefits for dependents who have other primary group health coverage will be subject to "carve-out". "Carve-Out" means that the Fund computes its regular benefits by applying any applicable deductibles, co-pays and coinsurance. The other plan's payment amount is then deducted from the Fund's payment amount and the difference, if any, is paid to the provider. |
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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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