United Food & Commercial Workers

Unions and Employers

Midwest Health and Pension Funds

UFCW Calumet Region Insurance Fund

Glossary

Eligible Dependents/Qualified Dependents

If you have elected Family Coverage and work enough hours to qualify for full-time coverage, your eligible dependents are:

  • your lawful spouse of the opposite sex or, effective 09/01/14, of the same sex when the marriage complies with the laws of the state in which the ceremony was performed  and Illinois recognizes same-sex marriage;
  • your children who are under 26 years of age.

Your children include:

  • your natural children;
  • your legally-adopted children or those for whom adoption proceedings have been started and who have been placed in your home by a licensed placement agency for the purpose of adoption; and
  • your step-children if the child’s natural parent lives with you.
      Your children also include a child under 19 years of age:
    • who is a first-degree relative for whom you have legal responsibility as the result of a court order;
    • who was covered under the Plan on December 1, 2010; and
    • who resides with you permanently and regularly for more than one-half of the year.

If a dependent was covered up to the date coverage would otherwise end because of reaching age 26, and if on that date the dependent:

  • is incapable of self-support due to mental retardation or physical handicap which began before the child attained age 26;
  • is dependent upon you for more than one-half of his or her financial support and maintenance; and
  • resides with you permanently and regularly for more than one-half of each year or lives in a treatment center,

then that dependent will be covered for so long as the incapacity and dependency continue, but not beyond the date on which your coverage ends.

Legal documentation of your dependent’s status, such as by an original registered marriage certificate, certified government-issued birth certificate or divorce decree, may be required by the Fund Office.

If both husband and wife are eligible as full-time employees, their dependent children are covered as dependents under both the wife and husband.

Intentionally Destructive Act

Knowingly failing to comply with a prescribed course of treatment, such as:

  • failing to take prescribed medication;
  • failing to enroll in and complete a course of treatment which has been recommended by a doctor for a chronic or acute condition, such as hypertension, diabetes or substance abuse;
  • failing to complete Medically Appropriate treatment or testing which is prescribed by a doctor, such as completing a course of treatment in an inpatient acute care facility or leaving an acute care facility against the medical advice of the doctor; and
  • self-administered overdose.

Medically Necessary and Appropriate

Services, supplies, treatments and confinements that are:

  • provided by or under the direction of a physician or other health care provider who is licensed and authorized to provide or prescribe it;
  • generally recognized by physicians as effective and essential for treatment of the injury or sickness for which it is ordered;
  • provided at the appropriate level of care and in the most appropriate setting based on the diagnosis;
  • the most “cost-efficient” supply or level of service that can be safely provided to the patient;
  • based on generally recognized and accepted standards of medical practice in the U.S. and is the type of care that could not be omitted without adversely affecting the patient’s condition or the quality of medical care; and
  • when hospital-confined, a service or supply is a medical necessity only if the diagnosis and treatment cannot be safely provided on an outpatient basis.

Services, supplies, treatments and confinements are not considered medically necessary if they are:

  • Experimental.
  • Investigative or primarily limited to research in their appplication to the injury or sickness.
  • Primarily for scholastic, educational, vocational or developmental training.
  • Primarily for the comfort, convenience or administrative ease of the provider or the patient or the patient’s family or caretaker.

The fact that a physician or other health care provider orders or recommends services, supplies, treatment or procedures does not in itself make them medically necessary.

Retail Prescription Program

The Prescription Drug Benefit is managed by WellDyneRx, a prescription benefit manager with a large network of pharmacies, called “participating pharmacies.” You receive the highest level of benefits when you fill your prescription at a participating retail pharmacy.

Usual and Customary Charge and Plan-Limited Allowance

Payment of benefits is limited to the usual and customary charge for covered services or to the Plan-limited allowances for certain surgeries or for certain equipment.

For treatment in the geographic area served by the PPO, the negotiated discounted fee amounts are the usual and customary charges. For treatment outside the area served by the PPO, the usual and customary charge is determined based on the average charge made by the majority of providers located within the geographic area.

For durable medical equipment and for home health care, the usual and customary charge is the charge negotiated between the Plan and providers who have agreed in writing to provide the equipment or services.

The Plan-limited allowance applies to

  • certain surgeries when performed at a non-PPO facility; and
  • the purchase price for certain medical equipment.

 

 

(Updated 05/17/16)