UFCW Midwest - Midwest Health and Pension Funds

United Food & Commercial Workers

Unions and Employers

Midwest Health and Pension Funds

When to Call the Fund Office

Cost-Containment Features of the Health Plan

Your Health Plan includes programs designed to manage your costs for health care and ensure that you get the most out of the benefits available to you and your family.

The Pre-Certification and Utilization Review Program lets you be assured that your medical treatment is covered under the Plan and is received in an appropriate and cost-effective manner.

The Second Opinion Program helps to determine if a proposed surgery is medically necessary, or if an effective alternative approach exists.

The Plan also offers you further opportunity to save on your out-of-pocket costs for health care through use of the BlueCross BlueShield of Illinois Participating Provider Option (PPO). Participants in this network of hospitals and doctors agree to provide health services at a lower rate than they normally charge. This means that your share of the cost for covered services is automatically reduced.

The ultimate decisions regarding your medical care must be made by you or your doctor. The Pre-Certification and Second Opinion Programs only determine the medical necessity of a service or supply according to the Plan’s benefits and provisions.

When to Notify Medical Cost Management

You can reach Medical Cost Management (MCM) by calling 800-367-9938.
 
Inpatient Hospital Admissions

MCM must be notified two weeks before the start of the hospital stay. If you do not pre-certify the hospitalization, an additional $100 deductible will be applied. This penalty does not apply to maternity stays that are less than 48 hours postpartum for a vaginal delivery and less than 96 hours postpartum for delivery by caesarian section.

Emergency Care

When emergency care is required that results in you or an eligible dependent being admitted to the hospital, call MCM within 48 hours of being admitted to the hospital. If you do not contact MCM, an additional $100 deductible will be applied.

Surgery

MCM must be notified at least two weeks before a scheduled surgery (inpatient or outpatient). If you do not pre-certify the surgery, an additional $100 deductible will be applied before any benefits are paid.

If you do not pre-certify expenses for bariatric surgery, it will not be considered medically necessary and the Plan will not cover the expenses. For specific information on bariatric surgery and weight loss treatment benefits, see the Comprehensive Medical Benefits section under your plan (either Plan D5 or Plan B5).

Second Opinion Surgery

You may be required to obtain a Second Opinion. The types of surgeries that require a Second Opinion are:

  • artery and vein surgery
  • back surgery
  • exploratory surgery
  • eye surgery
  • foot surgery (if it’s anticipated that the surgeons’ fees will be $1,000 or more)
  • genital surgery
  • intestinal surgery
  • joint surgery
  • nose surgery

If you have surgery without obtaining a Second Opinion when required, the Plan will pay 50% of covered expenses related to the surgery. You will be responsible for the remaining charges. The additional amount you pay will not count towards your out-of-pocket maximum.

Advanced Diagnostic Testing

It is required that you contact MCM (not BlueCross BlueShield) before undergoing advanced testing such as magnetic resonance imaging (MRI) scans, computerized tomography (CT) scans, positron emission tomography (PET) scans, Thallium stress tests, sleep studies, nerve conduction studies, or echo Doppler tests. If you do not pre-certify the expense for advanced testing, an additional $100 deductible will be applied.

The pre-certification must be done by MCM, not by BlueCross BlueShield—you or your doctor should speak directly with MCM at 800-367-9938.

Weight Loss Treatment

Before incurring expenses for weight loss treatment, including surgery, contact MCM for approval. If certain conditions are not met and if the expense is not approved, it will not be considered medically necessary and the Plan will not cover the expenses.

Nutritional Counseling

Expenses for nutritional counseling sessions are covered if the sessions are ordered by your doctor as part of a comprehensive treatment plan and if approved by MCM at the Fund Office. If the expense is not approved, it will not be considered medically necessary and the Plan will not cover it. For specific information on Nutritional Counseling benefits, see the Comprehensive Medical Benefits section under your plan (either Plan D5 or Plan B5).

Skilled Nursing Facility Care, Rehabilitation Therapy, Home Health Care and Hospice

Before incurring expenses for care in a skilled nursing facility, for rehabilitation therapy, for home health care, or for care in a hospice, you must contact MC for approval. If the expense is not approved, it will not be considered medically necessary and the Plan will not cover it.

Durable Medical Equipment

Before purchasing or renting durable medical equipment, you should call MCM for approval. If the expense is not approved, it will not be considered medically necessary and the Plan will not cover it.

Physical Therapy

Physical therapy is limited to 25 sessions per injury or illness. Additional benefits may be payable for treatment of certain conditions. These additional benefits must be pre-certified by MCM or payment will be limited to 50% of covered expenses. For specific information on physical therapy benefits, see the Comprehensive Medical Benefits section under your plan (either Plan D5 or Plan B5).

Occupational Therapy

Occupational therapy is limited to 25 sessions per injury or illness. Additional benefits may be payable for treatment of certain conditions. These additional benefits must be pre-certified by MCM or payment will be limited to 50% of covered expenses. For specific information on occupational therapy benefits, see the Comprehensive Medical Benefits section under your plan (either Plan D5 or Plan B5).

Penalties for Failure to Notify MCM

If you do not notify MCM to pre-certify expenses for your hospital stay, for surgery, or for advanced diagnostic testing, an additional $100 deductible, called a Non-Compliance Deductible, will be applied.

If you have surgery without obtaining a Second Opinion when required, the Plan will pay 50% of all covered expenses related to the surgery. You will be responsible for the remaining charges. The additional amount you pay does not count towards your out-of-pocket maximum.

If you exceed the 25 session limit for Physical Therapy or for Occupational Therapy without first pre-certifying the expenses, the Plan will pay 50% of covered charges.

If you have expenses for:

  • nutritional counseling;
  • weight loss treatment, including surgery;
  • skilled nursing facility care;
  • rehabilitation therapy;
  • home health care;
  • hospice care; or
  • durable medical equipment,

without first getting the expenses approved, they will not be considered medically necessary and the Plan will not cover them.

BlueCross BlueShield Participating Provider Option

BlueCross BlueShield has made arrangements with certain hospitals and doctors to provide health care to you and your eligible dependents at lower rates than normally charged.

To request a listing of network hospitals in Illinois, contact the Fund Office. For hospitals and doctors inside or outside of Illinois, go to www.bcbs.com and click on “Find a Doctor or Hospital” or call 800-810-BLUE (2583).

Simply by choosing a hospital and doctor in the PPO network and showing your Health ID card when you receive medical care, you will receive a discount on your medical bill. Discounts vary and may change from time to time, but the Plan will pay a greater portion of your expenses when you use a PPO hospital and doctor.

You save three ways when you use the BlueCross BlueShield Participating Provider Option:

  • Your percentage is applied to a discounted fee;
  • Your percentage is smaller; and
  • You avoid the extra $400 deductible charged for using an out-of-network hospital.

 

(Updated 02/24/16)