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Surgical Benefits and Information

Your plan may not include every benefit mentioned. Refer to your plan booklet to verify which benefits are included in your plan.

Overview of Surgical Benefits

Benefits are payable for surgery and related charges for conditions covered under the Plan. The benefit rate is:

  • 85% for hospital charges at a BlueCross BlueShield PPO hospital, and
  • 80% of the BlueCross scheduled allowance for physician and related charges.

Certain penalties apply if a non-PPO hospital is used on a non-emergency basis:

  • you must pay a $400 deductible which is in addition to your Annual Deductible, and
  • benefits are payable at 65%.

BlueCross BlueShield Participating Provider Option (PPO)

When you use a PPO hospital, the charges are substantially discounted and paid at the higher 85% benefit rate. Many quality hospitals and physicians are a part of the network, including world-renowned healthcare providers.

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. Expenses that are not covered by the Health Plan are not subject to a discount.

To request a listing of BlueCross BlueShield PPO hospitals in Illinois, click on PPO Hospital Listing. 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).

A Word of Caution Regarding Non-PPO Surgical Centers

A large number of appeals are filed each year by employee-members who have surgery performed at outpatient surgical centers that are not a part of the BlueCross BlueShield PPO network. These centers often charge twice the amount that a PPO hospital or surgical facility would charge. Remember, Plan benefits are limited to the usual and customary charges that are normallycharged. There is no reason to be exposed to thousands of dollars of personal liability when a non-PPO facility is used. Why use such a clinic when you could have your surgery at a prestigious university hospital for half the cost?

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).

Surgery at 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

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.

Pre-Certification Required for Non-Emergency Surgery

To receive your full benefits, the Fund Office must be notified of a non-emergency surgery. The representatives at Medical Cost Management (800-367-9938) will be available to answer any questions you may have regarding coverage and to help insure that you comply with Plan requirements regarding second surgical opinions.

If you do not pre-certify your surgery, an additional $100 deductible will be applied before any benefits are paid.

Second Opinion Requirement

You may be required to obtain a second opinion in order to receive full benefits. The types of surgeries that require a second opinion are:

  • artery and vein surgery
  • back surgery
  • breast surgery
  • digestive system surgery
  • exploratory surgery
  • eye surgery
  • foot surgery if the surgeons’ fees are expected to be $2,000 or more for any one surgery or for a series of surgeries
  • genital surgery
  • joint surgery
  • nose surgery

If a second opinion is not obtained, benefits will be paid at 50% after satisfaction of the $250 Annual Deductible.

The second opinion must be provided by a medical doctor who is board-certified in the appropriate medical specialty as determined by the Board of Trustees. Neither the doctor nor anyone in his or her office may be financially involved with the office of the doctor who will perform the surgery. To be certain the second opinion doctor meets the Plan requirements, be sure to contact Medical Cost Management (800-367-9938).

Pre-Surgery Testing

Pre-surgery testing includes necessary diagnostic x-rays and lab tests performed prior to surgery.

Diagnostic x-ray expenses are payable at 80% after satisfaction of the $250 Annual Deductible.

Covered laboratory testing is payable at 85% after the Annual Deductible or at 100% with no Annual Deductible if you have the laboratory 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.

Weight Loss Treatment

Before incurring expenses for weight loss treatment, including surgery, you must  contact Medical Cost Management (800-367-9938) 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 it.

For persons with a known history of morbid obesity, the following services are covered:

  • 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 (800-367-99.8) for additional details and referrals to a Fund-approved program.

Dental Surgery

Generally, dental surgery, including anesthesia, is covered under the Dental Benefit when surgery is performed in a dentist’s office or at an outpatient clinic. However, if it is medically necessary for you to have dental surgery in the hospital, the Plan will pay 50% of the covered hospital charges. This is in addition to benefits payable under the Dental Benefit for the dental surgeon and anesthesia.

The hospitalization must be pre-certified by Medical Cost Management (800-367-9938).

Income Protection

Surgery often results in a period of disability during which you cannot return to work. In this situation, Income Protection Benefits may be available to you if you are covered under Plan D5 as a full-time employee-member (Plan B5 does not include this benefit). For greater details, go to the Income Protection Benefit description or to People Often Ask About Disability Income Protection pages of this website.

Continuation of Medical Coverage

If your doctor finds medical reasons based on objective proof that make it essential for you to stop working (total disability), then you may be eligible under the federal Family and Medical Leave Act for up to a 12-week leave-of-absence. During the leave-of-absence, your employer will continue to make contributions for you into the Health Fund to maintain your health coverage.

If you remain disabled after the 12-week period or if you do not qualify for a leave-of-absence under the Family and Medical Leave Act, you may receive an extension of your medical coverage of up to six months. To be considered for an extension, you must immediately file a claim form, completed by you and your store manager; also, your doctor’s statement of disability must be included.

If you remain disabled at the end of the extension or if you do not qualify for an extension, you will have to make self-payments to continue your coverage. Contact the Fund Office to find out about self-payments under COBRA to continue your coverage.

If you stop working or do not return to work while you are not totally disabled, all your coverage will terminate regardless of any employer-approved leave of absence. Under the Federal law, COBRA, you may make self-payments to the Plan to continue your coverage. Contact the Fund Office for details.

(Updated 11/06/15)