The Plan provides coverage for hospitalization and surgery—including organ transplants—for you and your eligible dependents.
- Charges for a semi-private hospital room are covered at 100% of the allowance up to $7,000 per spell of illness.
- Covered expenses related to a surgery are covered at 80% after you’ve satisfied your annual deductible.
- You may obtain a second opinion at no cost to help you determine whether or not a surgery is necessary.
- The anesthesiologist assigned to your surgery may not participate in the UHC network. This means you will have to pay 20% of the allowed amount plus any amount over the allowance.
What You Need To Do
- If you are going to be hospitalized, call UHC at 1-800-850-1418 to have your hospital stay pre-authorized to make sure your expenses are covered to the fullest extent possible.
- If your doctor recommends elective surgery, you may contact another physician to obtain a second opinion.
What is a “physician?”
A physician is a doctor, chiropractor, podiatrist, psychologist, optometrist, or surgeon licensed to practice medicine or perform surgery under the laws of the state where such services are performed, and who is acting within the scope of his license. A duly licensed practitioner, who, under the supervision of a physician, performs services that would be covered under this Plan if performed by the physician, is also treated as a “physician.”
Covered Hospital expenses are paid at 100% of the allowance for expenses up to the first $7,000 per spell of illness. After that, covered hospital expenses are paid at 80% of the allowance. No deductible applies.
Covered Hospital Expenses include charges made by a hospital for:
- semi-private accommodations
- use of the intensive care or coronary care unit
- use of the operating room or other specialized facilities
- diagnostic testing
- other eligible ancillary charges
What is a “spell of illness?”
A spell of illness is a period beginning when you first are confined in a hospital, nursing home, or other approved facility and ending when you are discharged and:
- you recover completely from the condition causing the confinement
- you go at least one year during which you are not confined again for the same condition
A part of the Fund’s agreement with UHC is the “utilization” or “pre-admission” review program. When you are going into the hospital, the Plan strongly recommends that you call UHC case management and review services (CARE Program) at 1-800-850-1418. Doing so will not only ensure the quality of the services you receive both in the hospital and from your attending physician, but it can also save you hundreds, if not thousands, of dollars in hospital and doctor charges.
When your doctor schedules a hospitalization for you, the doctor or the hospital will call UHC for information about benefits, eligibility and pre-authorization. Generally, UHC will review the clinical information necessary to determine eligibility for benefit coverage and will verify eligibility and basic benefits for services that meet clinical guidelines for medical appropriateness. The UHC case management service (CARE Program) will, if they establish clinical eligibility for coverage, pre-authorize the hospital stay. They will then monitor your hospital stay and assist in discharge planning, equipment rental, home health care, and other appropriate services.
The CARE Program is designed to ensure that post-hospital services are covered to the full extent allowed under the Plan. This will help minimize your out-of-pocket expenses and will allow you to take advantage of any discounts offered. The case management service is available nationwide, regardless of whether your doctor or hospital is a member of UHC.
! EWTF will not cover hospitalization for a procedure if it is normally provided on an outpatient basis unless UHC approves the hospital stay in advance.
Prior Authorization Requirements and Procedures
If you are scheduled to be admitted to a hospital on a non-emergency basis, please take time to call UHC CARE Program at 1-800-850-1418 for prior authorization. While this call may take a few minutes of your time, making the call could save you money.
The Plan will pay 80% of the allowance, after you’ve satisfied your annual deductible, for charges related to surgery such as:
- charges by physicians and surgeons in or out of the hospital (including attending physician, consulting physician or anesthesiologist)
- services of a licensed speech therapist or physiotherapist (prior authorization by UHC is required prior to beginning any treatment or services)
- anesthesia and its administration
- breast reconstructive surgery following mastectomies
- treatment of a fracture or dislocation of the jaw, oral surgery, or treatment of natural teeth, if medically appropriate as the result of, and within 12 months after, an accidental injury
- 25% of surgeon’s charges to cover an assistant or co-surgeon
- emergency medical care expenses
If you or your dependent receives outpatient surgery at an approved facility, the Plan will pay 100% of the allowance for the facility fee to the first $7,000 in covered expenses. After that, the Plan will pay 80% of the allowance.
What is an “approved facility?”
An approved facility is a legally operated institution, other than a hospital, that provides care and treatment through medical, diagnostic or surgical facilities on the premises, under supervision of a physician and approved by the Board of Trustees. This term may include: ambulatory surgery centers, walk-in medical centers, birthing centers, hospices, substance abuse rehabilitation facilities, acute care facilities, and facilities for the treatment of mental or nervous conditions. A determination by the Board of Trustees as to whether or not an institution constitutes an approved facility is definite.
To help eliminate unnecessary surgery, you may wish to obtain a second surgical opinion before undergoing elective (non-emergency) surgery. The second opinion must be performed by someone other than your surgeon and not affiliated with your surgeon.
The Plan pays the full cost of obtaining a second surgical opinion. If the first and second opinions differ, the cost of a third opinion is also covered, on the same terms as the second surgical opinion.
If the second opinion is the same as your surgeon’s, you will have added peace of mind. If the consultant advises you against the operation, you may obtain a third opinion. Regardless of the outcome, if you still want to proceed with the surgery, you are free to do so. The choice is yours.
What’s Not Covered
No benefits are payable in connection with a second surgical opinion relating to the following:
- a consultation with anyone who is not certified to perform the proposed surgery
- more than two consultations with a surgeon after the initial determination, in connection with the proposed surgery
- any consultation with a physician who performs the surgery or has a financial interest in the outcome of the recommendation
- any consultation in connection with a proposed surgery for which a surgical expense benefit would not be payable under this Plan
- any consultation unless the patient is examined in person by the surgeon rendering the second opinion
The cost of an organ transplant is covered the same as any other surgery, provided the following conditions are met:
- the transplant procedure is not considered experimental or investigational by the Board of Trustees
- patient screening, including an opinion rendered by a qualified medical professional employed by the Trustees, confirms the appropriateness of the transplantation
- the patient is admitted to a transplant center program at a major medical center approved by the Board of Trustees
In addition, the UHC network includes Transplant Resource Services, which provide network access to qualified transplant facilities that have high-quality, cost effective transplant care.
Charges for immunosuppressant drugs prescribed in connection with organ transplants are considered medical expenses and are included in the calculation of Lifetime Benefits and Annual Limits shown in the Summary of Benefits on here.
What’s Not Covered
- charges for any individual not covered by this plan
- charges for a donor covered by this Plan if the charges are not directly related to the transplant procedure itself
UHC’s Bariatric Resource Services (BRS) administers this program, available January 1, 2013. Certain criteria determined by BRS must be met prior to a patient having surgery, in order for the surgery to be covered under the Plan. (For more information about this surgery and BRS, see here in the “Wellness Benefits That Are Covered” section).