Your Health Care Benefits

Understanding Your Medical Benefits

Your Plan provides comprehensive medical coverage for you and your eligible dependents. The Plan participates in the UnitedHealthcare Choice Plus Network (UHC) to provide quality health care, convenience and savings to you and to the Plan.


Fast Facts

  • When you visit a UHC provider for medical care, the provider accepts the discounted pre-determined rate for payment. You will need to pay your Patient’s Portion, if applicable.
  • If you do not visit a UHC provider, you are responsible for payment of the balance that the provider charges above the UHC rate in addition to your Patient’s Portion.
  • Unless otherwise noted, the Medical Expense Benefits are available to all eligible Active Electrical Worker Employees, Active Non-Bargaining Unit Employees, Retired Employees, Surviving Spouses and their dependents. These benefits are subject to the limitations listed here.

After you meet your annual deductible, most covered services are paid at 80% of the allowance. You’re responsible for paying the other 20% of the allowance—your Patient’s Portion. If you visit a non-UHC provider, you may be responsible for additional expenses as well. Certain expenses are limited to the annual $10,000 out of pocket maximum, with the understanding that you must provide written proof to the Fund Office that you have paid $10,000 out of pocket.

What is a “covered medical expense?”

Covered medical expenses are only those expenses that meet clinical guidelines for medically appropriate treatments, services, and supplies relating to the benefits provided by this Plan that are performed, recommended, approved or prescribed by the attending physician and are not excluded under the terms of the Plan.

Unless specifically addressed in the following pages, benefits provided under this Plan are subject to the following:

Annual Deductible (calendar year)*

Per Individual

$150

Per Family

$300

*The $300 family annual deductible may be satisfied by covered expenses from all family members, equaling in total the annual deductible amount. The total amount for any one person cannot exceed $150.

Annual Out-of-Pocket Maximum (calendar year)

Per family (after meeting annual deductible) effective January 1, 2009

$10,000

Lifetime Benefits (per individual)

(for all covered medical expenses, including mental health and alcohol and substance abuse benefits, but excluding prescription drugs other than immunosuppressant drugs prescribed in connection with organ transplants)

 

The Plan has increased the lifetime benefit it provides. In the past, once the Plan provided $1 million in total covered medical expenses,mental health and alcohol/substance abuse benefits were included in the $1 million lifetime maximum. Prescription drugs were not included unless immunosuppressant drugs were prescribed in connection with an organ transplant.

 

However, effective January 1, 2011, the Plan increased its coverage to provide that once the Plan has provided $1 million in medical expenses on behalf of an individual, it will pay for additional medical expenses that are considered “essential health benefits” at a rate of 50%.

 

The definition of the term “essential health benefits” is found in section 1302 of the PPACA and implementing regulations issued by the federal government. Until the federal government issues regulations further defining the term “essential health benefits,” the term includes items and services covered within the following categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and, pediatric services, including oral and vision care.

 

There are different lifetime benefit rules for H Plan participants. These rules are described here.

 

Annual Limits

 

Overall annual limits will exist during 2011, 2012, and 2013 with respect to “essential health benefits” as defined above. The annual maximums over these three years are as follows:

 

Plan Year

Annual Maximum

2011

$1,000,000

2012

$1,250,000

2013

$2,000,000

There are different annual limitation rules for H Plan participants. These rules are described on here.

Advantages of Using the UHC Choice Plus Network

In order to ensure quality health care, the Plan participates in the UnitedHealthcare Choice Plus Network (UHC). The organization works with thousands of the country’s top medical providers, including doctors, medical labs and hospitals.

When you go to a UHC provider, the provider will:

  • accept assignment for services
  • ask members to pay their estimated financial liability at the time of service
  • agree to accept the allowance as payment in full, provided you pay the deductibles and Patient’s Portion within thirty (30) days after EWTF processes the claims

What is the “allowance?”

The allowance is the amount the Plan has determined to be the cost for a particular service. If you use UHC Choice Plus Network providers, EWTF’s allowances are the same as the UHC allowances.

The Power to Save

Although you are not required to use UHC network providers, most of the participants and families covered under the Plan are saving themselves and the Plan money by using UHC doctors, hospitals, labs and other providers.

For example:

Let’s say David has to go to the doctor to receive treatment. The Plan has determined that the allowance for this service is $200 per visit both in-network and out-of-network. The example below compares what the Plan pays and what David pays in and out-of network.

UHC Doctor Non-Participating Doctor
The UHC doctor’s charge for this service is $250 The Non-Participating doctor charges $250 for this service

The allowed amount is $200

The allowed amount is $200

The Plan pays 80% of the allowance, or $160

The Plan pays 80% of the allowance, or $160

David’s Patient’s Portion is the remaining 20% or $40

David’s co-payment is the remaining 20% or $40

UHC doctor accepts $200 as full payment

David must pay the amount that is more than the allowance rate of $200, or $50

David’s out-of-pocket costs: $40

David’s out-of-pocket costs: $90

! Self-Funded Plan

UnitedHealthcare is not your insurance company. The EWTF Plan is “self-funded.” This means that your employer’s contributions—and any income earned from investments of your employer’s contributions—pay for the health care expenses that you and your fellow participants incur. The EWTF Plan makes the final decisions about what is covered and what is paid and EWTF writes the checks to pay benefits.

Provider Directories

For the most up to date information about all participating providers call the Fund Office at (301) 731-1050 or 1-800-929-EWTF or visit the UHC website at http://directory.uhis.com or the UHC link on the EWTF website (www.ewtf.org). You can also find the UHC link on the WellnessWorks website at www.ewtf-wellnessworks.org. This is the best way to get a list of all network doctors, hospitals, labs, emergency centers, etc. Be sure to check with your providers before you make a UHC appointment to be certain that they have not left the UHC network.

Find dental providers by visiting the OneNet website at www.onenetppo.com.

EWTF ID Card

When you and your family first become eligible in the Plan, you will receive information and an EWTF ID card that identifies you as a network member. You will need to use this card to receive network health care, prescription drugs and dental care. Your UHC Group Number is 78-340001. The last six digits of the 12 digit number appearing on your card will be used when submitting dental claims or picking up prescriptions at your local pharmacy.

Always identify yourself as an EWTF and UHC participant by showing your EWTF ID card to any doctor, pharmacy, dentist or other provider you visit. If the provider is a network member, you will start saving money right away.

Out-of-Pocket Maximum (Catastrophic Benefit)

The Plan limits the amount of eligible expenses you have to pay each year. Once you have provided written proof to the Fund Office that you have paid the out-of-pocket maximum of $10,000 per family in a calendar year, EWTF will pay 100% up to the allowance of your eligible expenses for the rest of the calendar year. This benefit provides much greater protection in those situations where an individual or a family may suffer a financial hardship due to a very serious illness or accident.

What the Out-of-Pocket Maximum Does Not Include

  • your annual deductible
  • services that are not covered under the Plan (i.e., cosmetic surgery, TMJ treatment, fertility/infertility treatments, etc.)
  • dental and vision
  • charges above the Plan’s allowance