UFCW Midwest - Midwest Health and Pension Funds

United Food & Commercial Workers

Unions and Employers

Midwest Health and Pension Funds

Comprehensive Medical Benefits

Your Plan pays a significant portion of your covered medical expenses and protects you from financial hardship in the event of serious illness or injury. The Plan covers non-occupational illnesses and injuries only.

This benefit provides coverage for many common medical needs.

Annual Maximum Benefit

Effective January 1, 2015, there is no limit on total payment for all covered expenses incurred during a calendar year.

Annual Deductibles and Benefit Rates

For most covered medical expenses, you must pay the first $325 of covered expenses each calendar year before the Plan begins to pay benefits. This is called the Annual Deductible.

If you use any non-PPO provider during a calendar year, you must pay an additional $50 Non-PPO Provider Annual Deductible.

Once you have satisfied the Annual Deductible, the Plan will pay the percentage specified in the Summary of Benefits for the cost of covered medical expenses. You are responsible for the difference.

Certain medical expenses are not subject to the Annual Deductible. These expenses are paid immediately at 100% up to the benefit maximum.

Non-PPO Hospital Deductible

If you are admitted to a hospital that is not a BlueCross BlueShield PPO hospital and it is not an emergency, you must pay a $450 deductible. This is in addition to the Annual Deductible and the Non-PPO Provider Annual Deductible.

Non-Compliance Deductible

If you are admitted to a hospital without having that admission pre-certified by Medical Cost Management at the Fund Office, you must satisfy an additional $100 deductible. The additional $100 deductible also applies to emergency care that results in hospital admission if Medical Cost Management is not contacted within 48 hours of the admission.

If you have a scheduled surgery, either inpatient or outpatient, and you do not pre-certify the surgery by contacting Medical Cost Management, an additional $100 deductible will be applied before any benefits are paid.

If you have advanced diagnostic testing done without having the expenses pre-certified by contacting Medical Cost Management, you must satisfy an additional $100 deductible before any benefits are paid.

Out-of-Pocket Limit

After you pay $2,650 (including the $325 Annual Deductible) in covered expenses during a calendar year, the Plan will reimburse covered medical expenses at 100% of allowable charges for the remainder of that calendar year.

Expenses that do not count toward the out-of-pocket limit are:

  • charges that exceed the usual and customary charge;
  • amounts you are required to pay either because you failed to pre-certify certain expenses or you otherwise failed to follow the Plan’s Utilization Review Program;
  • charges that the Plan pays at 50%; and
  • any charges that are not covered by the Plan.

PPO Providers–BlueCross BlueShield of Illinois

You have access to BlueCross BlueShield Participating Provider Option (PPO) hospitals and physicians under the Plan. PPO providers offer discounts on services to you. When you use a PPO hospital, the Fund is charged a discounted rate. When you use a PPO physician, you receive treatment at an agreed upon, discounted rate. The Fund shares these savings with you by reducing your out-of-pocket costs. The Fund also pays a higher percentage of your expenses when PPO hospitals are used.

Please note that charges by a non-PPO facility may be substantially in excess of the Plan’s usual and customary charges. These excess charges are not covered under the Plan. Additionally, certain surgeries have limited benefits payable if performed at a non-PPO facility (see next section below).

The BlueCross BlueShield PPO includes a large variety of first-rate hospitals and doctors, including world-renowned healthcare providers. Why not use a PPO physician and hospital to control your health care costs?

To request a listing of BlueCross BlueShield PPO hospitals in Illinois, contact Customer Service at the Fund Office. Or, go on-line and locate a PPO hospital or physician anywhere. Go to bcbs.com, click on “Find a Doctor or Hospital” and follow the instructions from there. Or call BlueCross BlueShield at 800-810-BLUE (2583).

Surgery at a Non-PPO Facility

When certain surgeries are performed at a non-PPO facility, benefits will be limited to the Plan-defined usual and customary charge or the following allowance, whichever is lower:

arthroscopy $ 3,200
cataract $ 3,000
colonoscopy $ 1,100
cystourethroscopy $ 1,500
elective abortion $ 750
endoscopy $ 1,100
epidural injections with fluoroscopy $ 1,300
foot—hallux valgus $ 3,000
foot—hammer toe $ 2,500
foot—other $ 2,500
gynecological $ 3,200
joint implant removal $ 250
nasal septum $ 3,500
skin disorder repair $ 250
tonsillitis-related $ 2,400

 

Covered Medical Expenses


The Plan provides coverage for the medical expenses listed below, provided you are under the care of a licensed physician and the covered services and supplies are medically necessary.

The following covered expenses are NOT subject to the Annual Deductible — benefits are payable immediately at 100% up to the specified maximum:

Laboratory Testing. Benefits are payable at 100% for covered laboratory testing if you have the tests conducted by:

 

  • a stand-alone outpatient laboratory, such as Quest Diagnostics or LabCorp of America; or
  • a physician who participates in the BlueCross BlueShield network and processes the tests in his or her office.

Benefits will be limited to 50% after the Annual Deductible if you have the tests conducted by a hospital or by a hospital’s outpatient laboratory department. Exceptions to this are testing done (1) when you are admitted to the hospital; (2) due to emergency care; (3) prior to surgery; or (4) related to cancer treatment at the same hospital. Benefits in these situations will be payable at 85% after the Annual Deductible.

Mammography. Benefits for a screening mammogram and its interpretation to detect the presence of breast cancer are payable up to $130, according to the following schedule:

 

  • age 35-39—one baseline mammogram
  • age 40 and up—annually

Expenses in excess of $130 are payable at 80% after the Annual Deductible.

Preventive Care. You are eligible for benefits up to $50 each calendar year for:

 

  • a routine physical exam
  • a PAP test
  • complete blood count, cholesterol test, multi-channel blood test and urinalysis
  • colon cancer screening if age 50 or older
  • Prostatic Specific Antigen (PSA) blood test

Expenses in excess of $50 are payable at 80% after the Annual Deductible.

Seasonal Flu Shot. You are eligible for benefits up to $30 each calendar year for a seasonal flu shot.

 

Benefits for the following covered expenses are payable, after satisfaction of the Annual Deductible, as shown in the Summary of Benefits and are subject to any rules and limitations explained under each item.

    • Hospital services and supplies, including:
      • room and board, up to the semi-private room rate
      • specialty care unit charges
      • Emergency Room charges
    • Surgery and related charges
    • Physician’s charges for surgery, radiotherapy procedures, or medical services
    • Outpatient treatment, services and supplies for illness or injury
    • Ambulatory surgical center service
    • Diagnostic x-ray and laboratory charges
    • X-ray, chemotherapy, radium, and radiation therapy
    • Anesthesia and its administration
    • Oxygen and its administration
    • Professional ambulance transportation to and from a local hospital or between local hospitals. Convenience transfers are limited to $300. Covered air ambulance expenses are limited to $15,000 in North America and $25,000 elsewhere.
    • Pregnancy. Federal law requires that benefits be provided to the mother for hospital confinement of at least 48 hours following a vaginal delivery or at least 96 hours following a cesarean section, unless the mother chooses to leave the hospital sooner. Your doctor or hospital is not required to obtain authorization for a length of stay that does not exceed 48 (or 96) hours.
    • Women’s Health and Cancer Rights Act of 1998. Under federal law, group health plans that provide medical and surgical benefits in connection with a mastectomy must provide benefits for certain reconstructive surgery. If you are receiving benefits under the Plan in connection with a mastectomy and elect breast reconstruction, federal law requires coverage in a manner determined in consultation with the attending physician and you, for:
      • reconstruction of the breast on which the mastectomy was performed;
      • surgery and reconstruction of the other breast to produce a symmetrical appearance; and
      • prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas.
    • Reconstructive treatment because of an accidental injury or congenital disease or anomaly that results in a functional defect or deformity from trauma, infection or other disease of the involved body parts.
    • Transplants. Donor-related expenses are not covered.
    • Varicose vein treatment. Benefits are limited to a lifetime maximum of $2,500 per leg, except for ulcerated conditions.
    • Skilled Nursing Facility Care, Rehabilitation Therapy and Hospice Care. Medically necessary care in a skilled nursing facility, rehabilitation therapy and hospice care are covered if pre-certified by Medical Cost Management at the Fund Office. The Plan will not consider these expenses medically necessary and will not cover them if you do not receive pre-certification for them.
    • Home Health Care. The Plan pays for the following services when provided by a Home Health Care Agency:
      • skilled nursing care by, or supervised by, a licensed nurse; home aides are not covered
      • administration of IV therapy
Covered medical expenses are limited to expenses that are pre-certified by Medical Cost Management at the Fund Office. Each visit by a member of the home health team will count as one visit.
    • Charges made by a registered nurse or licensed practical nurse, other than one who normally lives in your home or is a member of your or your spouse’s immediate family. Only Home Health Care expenses that are pre-certified by Medical Cost Management at the Fund Office will be covered.
    • Medical supplies, trusses, braces or supports, casts, splints and crutches. The following supplies are limited to a maximum per calendar year of:
      • 4 pairs of surgical stockings
      • 1 wig, up to a maximum of $150
      • 2 bras for a breast prosthesis
    • Durable medical equipment for therapeutic treatment. The purchase price for the following equipment is limited to:
      hospital bed $1.500
      custom wheelchair $12,000
      limb prosthesis $20,000
      scooter or other non-wheelchair transportation $2,600
      stander $3,000
      CPAP machine, complete $1,200
      CPAP machine replacement supplies for 6 months $200

Any expenses must be pre-certified by Medical Cost Management at the Fund Office.

    • Orthopedic or prosthetic appliances. The Plan will pay for the initial appliance, and after 5 years, one replacement for each 5 years of continuous use. Covered items include:
      • artificial limbs or eyes (limited to purchase price of $20,000)
      • external breast prosthesis
      • internal breast prosthesis (breast implant)
      • penile implant, but limited to one per lifetime
      • orthotic appliance
Cochlear implants are not covered.
    • Nutritional Counseling. Expenses for up to 4 nutritional counseling sessions per calendar year will be covered if the following conditions are met:
      • You must have a known history of diabetes, renal failure, hepatic insufficiency, morbid obesity, or a genetic metabolic disorder requiring diet modification.
      • The counseling must be ordered by your physician as part of a comprehensive treatment plan and the expense must be approved by Medical Cost Management at the Fund Office.
      • The counseling must be provided by a Registered Dietician or a comparably-credentialed professional.
    • Weight Loss Treatment. The Plan pays for the following services if you have a known history of morbid obesity:
      • Nutritional Counseling–Up to 4 counseling sessions per calendar year with a Registered Dietician (or a comparably-credentialed professional) when ordered by your physician as part of a comprehensive treatment plan and the expenses are approved by Medical Cost Management at the Fund Office.
      • Bariatric Treatment and Management–Up to 6 visits per calendar year with a physician (MD or DO) when part of a comprehensive treatment plan and the expenses are approved by Medical Cost Management at the Fund Office.
      • Bariatric Surgery–The patient must be enrolled in a Fund-approved multi-discipline, physician-supervised nutrition and exercise program of at least 6 months in duration. Any recommended surgery must be pre-certified by Medical Cost Management at the Fund Office and must be performed at a Fund-approved Bariatric Surgery Center of Excellence.
      Contact Medical Cost Management at the Fund Office for additional details and referrals to a Fund-approved program.
    • Bone Density Scan. Benefits are payable once every four calendar years if you are age 45 or older.
    • Chiropractic therapy. Benefits are limited to $1,500 per calendar year for charges by a chiropractor for treatment of:
      • the back, neck, spine or vertebra; and
      • conditions due to non-work-related strains, sprains and nerve root problems
    • Physical therapy. Benefits are limited to 25 sessions per injury or illness.

A session includes an evaluation and no more than three medically-appropriate modalities or other services for up to one hour per day.

Additional benefits may be payable for treatment of more than one musculoskeletal, neurological, digestive, genitourinary or skin systems or for loss of any special senses function. These additional benefits must be pre-certified by Medical Cost Management at the Fund Office or payment will be limited to 50% of covered charges.

    • Occupational therapy. Benefits are limited to 25 sessions per injury or illness.

A session includes an evaluation and no more than three medically-appropriate modalities or other services for up to one hour per day.

Additional benefits may be payable for treatment of more than one musculoskeletal, neurological, genitourinary or skin systems or for loss of any special senses function. These additional benefits must be pre-certified by Medical Cost Management at the Fund Office or payment will be limited to 50% of covered charges.

    • Speech therapy. Benefits are limited to 25 sessions per injury or illness.

A session includes an evaluation and treatment provided on a single day not to exceed one hour.

    • Cardiac and pulmonary rehabilitation. Benefits are limited to 30 sessions per event.

A session is a supervised rehabilitation service of no more than one hour per day and may further include one low level stress test per event.

  • Mental Health. Effective December 1, 2013, covered expenses for mental health treatment are payable the same as most other conditions.
  • Substance Abuse. Effective December 1, 2013, covered expenses for substance abuse treatment are payable the same as most other conditions.
  • Intentionally Destructive Act. Benefits are payable at 50% if you are not of diminished capacity and you do not comply with the requirements necessary to receive unreduced benefits. Additionally, if you are receiving treatment in an inpatient acute care facility and leave against the advice of the doctor, then all expenses, including those already incurred, are payable at 50%.
  • Dental treatment due to accidental injury to sound and natural teeth within one year from the date of the accident.
  • Voice communication machines. The Plan pays up to a $7,500, lifetime maximum.
  • Hearing Aid. Benefits are payable at 80% up to $500 in a five consecutive year period for covered charges for a hearing examination and hearing aid. 

    Covered charges include the following hearing expenses:

    • an otologic examination performed by a physician
    • an audiologic examination performed by a physician or a licensed audiologist
    • the hearing aid (monaural or binaural) prescribed as a result of an examination. This generally includes ear mold(s), the hearing aid instrument, the initial batteries, cords and other necessary ancillary equipment.
    • a follow-up consultation within 30 days following the delivery of the hearing aid

    The following hearing expenses are not covered:

    • expenses for more than one hearing examination without a hearing aid being obtained
    • replacement batteries
    • charges for repairs, servicing and alterations

What’s Not Covered


Expenses that are not covered under the Comprehensive Medical Benefit include but are not limited to the following:

  • custodial care, educational and training care
  • cosmetic treatment or complications thereof
  • expenses for hormone therapy, artificial insemination or any other direct attempt to induce or facilitate fertility or conception
  • genetic testing, except for amniocentesis, government-mandated neonatal testing, and testing for the purpose of determining the medical appropriateness of therapy for newly-diagnosed breast cancer
  • charges related to a surrogate pregnancy
  • naturopathic or homeopathic services and substances
  • personal hygiene, comfort or convenience items such as air conditioners and humidifiers or physical fitness equipment
  • over-the-counter supplies
  • foods and nutritional supplements including, but not limited to, home meals, formulas, diets, vitamins and minerals (whether they can be purchased over-the-counter or require a prescription), except when provided through a feeding tube as sole nutrition
  • shoes, for any reason
  • wigs or toupees except when made necessary due to loss of hair resulting from treatment of a malignancy or permanent loss of hair from an accidental injury (limited to one per calendar year up to a maximum benefit of $150); hair transplants, hair weaving or any drug if such drug is used in connection with baldness
  • breast reduction surgery except for reconstruction due to breast cancer
  • skin or fat removal surgery for any reason
  • immunizations, except as specified under Seasonal Flu Shot
  • routine screening tests, except as otherwise noted
  • routine foot care such as the cutting and trimming of toenails
  • marriage counseling or treatment for anti-social behavior which is not the result of a mental or nervous disorder
  • services or supplies for weight reduction by diet control or behavior modification, with or without drugs, except as provided under Weight Loss Treatment
  • transportation other than local ambulance service and covered air ambulance
  • expenses for and related to travel for you or a physician
  • donation of an organ or tissue
  • blood storage charges except for use for an anticipated covered medical condition for a period not to exceed six months
  • blood donated by family members or others specifically for your use
  • expenses for home blood pressure monitoring or home uterine monitoring equipment, for any reason
  • muscle stimulators in excess of $500
  • cochlear implants
  • snoring correction devices, unless sleep apnea has been diagnosed
  • repair of, or operating supplies for, durable medical equipment
  • services performed on or to the teeth, nerves of the teeth, gingivae or alveolar processes except for tumors or cysts or unless resulting from an accidental injury to sound natural teeth
  • eye refractions, eyeglasses or their fitting
  • procedures for surgical correction of myopia and/or other refractive errors
  • vision therapy
  • non-prescription (over-the-counter) drugs or medicines
  • vitamins, including vitamins requiring a written prescription. However, pre-natal vitamins are covered.
  • smoking cessation products, including those requiring a prescription
  • contraceptives or medications for contraception, including medications or contraceptives requiring a written prescription, regardless of intended use
  • charges for infection control and medical waste disposal
  • anything excluded under General Exclusions and Limitations.

  

(Updated 01/13/17)