Your Health Care Benefits

Wellness Benefits That Are Covered

WellnessWorks – Wellness Initiative

The Trustees recognize that many of the strategies of the managed care era that were used to control health plan costs have lost their effectiveness. As a result, the Trustees have made a commitment to approach health care cost management in a more enlightened and holistic manner. By making this commitment, the Trustees are in the forefront of a new era for health cost management—total health management. They have named this wellness initiative WellnessWorks.

The patient-centered tools that WellnessWorks utilizes are designed to address the real causes of medical cost escalation: consumer lifestyles, waste in the health care system, poor quality care, poor care coordination and poor preventive care.

WellnessWorks is not a short-term strategy and requires hard work on the part of the Trustees, their advisors, and our Plan participants. Through the coming years, the Trustees will deploy a number of initiatives and projects that will target identified areas of cost and utilization based on claims data and predictive models. The Trustees’ vision of a new health plan business model includes:

 

  • Perform health risk profiling that measures the health of the Plan’s population
  • Through predictive modeling, identify high-risk and at-risk participants
  • Organize target interventions through a combination of wellness, disease management and case management
  • Empower members and physicians through access to information technology
  • Assist participants with personal health advocacy programs
  • Adopt plan designs that complement this model


Fast Facts

  • The following benefits are payable at 80% after you’ve met your annual deductible:
  • a routine physical exam each year for you and your spouse
  • routine wellness exams for your children, including immunizations
  • well woman exam and pap smear
  • one mammogram per year starting at age 35

Disease Management Program

The Plan provides a program to help you and your dependents better manage chronic conditions such as asthma, diabetes, heart disease and hypertension in order to live a healthier life. The Disease Management (DM) Program is designed to do these things and starts with a phone call. Taking the call is completely free, voluntary and confidential.

How the Program Works

UHC reviews medical and prescription drug claims to determine those individuals who have been diagnosed with one or more chronic conditions who might benefit from having additional medical support for their chronic condition. If you have one of the chronic conditions that the Health Plan is targeting, a nurse from UHC will call you to talk to you about your health condition. There is no cost to you, and participation is completely voluntary. He or she will determine if your condition is well-controlled or if you could benefit from some additional one-on-one discussions with a nurse over the phone.

On the calls, you can ask questions, get more information about your condition and how best to treat it. For example, the UHC nurse can help you prepare for your next doctor’s appointment and gather questions to take with you. Your nurse can also reach out to your doctor’s office on your behalf—for example if he or she has a question about multiple medications you’re taking and potential drug interactions. The information from the nurse is meant to supplement your physician’s care—it is not meant to replace it or interfere with it. They are medical experts trained to provide patient care. The conversations you have with the UHC nurse are completely confidential.

What happens on the first call

First, a UHC nurse will call you on the number you provided to the Plan when you first enrolled (or updated your contact information with the Fund Office). The Plan has engaged UHC to provide chronic condition management counseling to Plan participants. UHC is a recognized confidential “partner” with EWTF, and the contact information supplied to UHC is protected under the law.

When the UHC nurse calls you, you should see “UnitedHealthcare” on your caller ID. When you answer the phone, the nurse will give you his/her name and phone number. All of the nurses that provide health management counseling for UHC are located in Buffalo, New York.

During the call

The nurse will ask you a few questions about your condition, how you are treating it and how that treatment is going. With a short assessment, the nurse will be able to determine if you would benefit from additional telephone counseling, which is completely up to you. If the nurse determines your condition is well-controlled, or if you decline to participate, you will not receive any additional phone calls.

After the call

If you could benefit from one-one-one counseling with a UHC nurse, you and the nurse can determine the date and time of your next call. That’s all there is to it. It’s your chance to ask questions from a qualified health professional and get ideas for additional ways to manage your care—all designed to keep you healthy.

If You Miss the Call

If you’re unable to answer the phone, the UHC nurse will leave a message, and you can call back at a convenient time.

If a UHC nurse is unable to reach you by phone, the nurse may try to contact you again via phone or by U.S. mail.

Speaking with the nurse is completely optional and there is no charge. While you are encouraged to speak with a UHC nurse about your medical condition, there is no penalty for not talking to a nurse.

Eligibility for the Disease Management Program

Participants and dependents who have chronic conditions like asthma, diabetes, and heart disease receive free “counseling/coaching” from a UHC registered nurse via the telephone. Plan participants who know they have a chronic condition should expect a call from a UHC nurse.

Contacting Your Child

All participants and their dependents with a chronic condition are eligible for this program. If your child is under age 18, you, as the parent, will be contacted to participate in the telephone counseling/coaching on behalf of your child. Your child will not be contacted directly.

Program Ambassadors

The Fund has “Ambassadors” for the program who are willing to take your questions and talk to you about the program and any concerns you have. Please contact the Fund Office at 301-731-1050 or 1-800-929-EWTF if you would like information about contacting an “Ambassador.”

Program is Confidential and Free

The Trustees, the Union, and contributing employers will not know who is being contacted by the program, nor will they have any knowledge of anything related to participants’ health conditions or discussions with UHC. This service is part of your covered benefits under the Plan. The cost of the program is covered in full by the Plan.

Participate in this Program Even if Your Doctor is Already Treating You

Research shows that over 45% of people with a chronic condition are not getting all of the medical care that they should receive. The result of not getting certain types of care can result in unnecessary medical complications or hospitalizations. The Trustees want you to live the best life possible and get the best care you can. They hope this program will succeed in doing that.

Routine Physical Exam for member and spouse

You and your spouse are eligible for an annual physical exam. The Plan will pay 80%, after you’ve met your annual deductible. NOTE: Medicare-eligible retirees and their spouses are entitled to the Routine Physical Exam benefit only if the services are covered by Medicare. The Plan’s annual deductible does not apply to Medicare-eligible retirees.

The Routine Physical Exam also includes coverage (including administration) for Zostavax, a vaccine for the prevention of herpes zoster (shingles). NOTE: The Zostavax vaccine benefit is not subject to the annual deductible and is also available to Medicare-eligible retirees and their spouse (provided such retirees or spouse are not enrolled in a separate Medicare Part “D” prescription plan).

Child Wellness Visits and Examinations

Your eligible children are covered under this Plan for regular wellness visits and examinations. Your benefit includes the required childhood immunizations. Benefits are paid at 80% of the allowance after you’ve met your annual deductible according to the following maximums:

  • children from birth through age 23 months for a maximum of five visits
  • children age two through age 18 for a maximum of one visit per year

Well Woman

EWTF encourages women to have an annual wellness exam. The Plan provides the following at 80% of the allowance after you’ve met your annual deductible:

  • one routine pap smear per year and related office visit
  • one mammogram per year for women age 35 or older

Bariatric Surgery

Summary

UnitedHealthcare’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.

Bariatric Resources Services (BRS)

BRS is a surgical weight loss solution for those individuals who qualify clinically for bariatric surgery. Specialized nurses provide support through all stages of the weight loss surgery process. The program is dedicated to providing support both before and after surgery. Nurses help with support in preparation for surgery, information and education important in the selection of a bariatric surgery program, and post surgery and lifestyle management. Nurses can provide information on the nation’s leading obesity surgery centers, known as Centers of Excellence (COE). A COE is a facility that is a top performing, quality bariatric center that delivers improved clinical and economic outcomes.

All authorization for, information about and enrollment for bariatric surgery must be initiated through the BRS Program. Covered participants seeking coverage for bariatric surgery should notify BRS as soon as the possibility of a bariatric surgery procedure arises (and before the time a pre-surgical evaluation is performed) by calling the Bariatric Resource Services program at (888) 936-7246 to enroll.

Criteria

The Plan covers surgical treatment of morbid obesity, provided all of the following are true:

  • you are over the age of 18 and are physically mature
  • you have a minimum Body Mass Index (BMI) of 40, or > 35 with at least 1 co-morbid condition present
  • one (1) surgery is covered per lifetime unless medically necessary complications arise
  • you must use a UnitedHealthcare BRS Bariatric COE
  • you must have completed a multi-disciplinary surgical preparatory regimen, which includes a psychological evaluation
  • you must have completed a 6-month physician supervised diet documented within the last 2 years (a physician supervised diet is not covered by the Plan)
  • revisions (performed primarily for weight gain) are excluded from coverage under the Plan
  • excess skin removal is not covered under the Plan, unless medically necessary

Once the criteria are met and it’s time to choose where the patient has the procedure, the case manager will direct the patient to a COE.

Benefit Coverage

  • The Program is available beginning January 1, 2013. Only eligible expenses incurred on and after this date will be covered under this benefit.
  • The benefit provides for one (1) surgery per lifetime
  • The all inclusive maximum lifetime benefit is $100,000. This includes benefits paid at the normal coverage rate for the surgery plus all procedures and pre- and post-operative expenses, but does not include services resulting from complications due to the surgery. After the $100,000 maximum is reached, eligible expenses are covered at 50%.

Questions

Questions that are specifically related to the Bariatric Resource Services program should be directed to (888) 936-7246.

Zostavax (vaccine to prevent herpes zoster)

Routine Physical Examination includes coverage (including administration) for Zostavax, a vaccine for the prevention of herpes zoster (shingles). Benefits are paid at 80% of the allowance and are not subject to the annual deductible.

! The Zostavax vaccine benefit is also available to Medicare-eligible retirees and their spouse, provided such retirees or spouse are not enrolled in a separate Medicare Part “D” prescription plan, and is not subject to the annual deductible.

Gardasil

In general, vaccines and immunizations are covered only for patients up to the age of 18. However, in light of the indications of the effectiveness of Gardasil and the benefits of helping to protect against HPV Types, the benefit applies to all eligible members through the end of their 26th year and dependents through the end of the month in which they reach age 26. Benefits are paid at 80% of the allowance after the annual deductible is met.

EWTF Health Fair

The EWTF WellnessWorks Program, in conjunction with the IBEW Local 26 Family Picnic, conducts Health Fairs that offer a variety of free health screenings to all Plan participants and their families. Details regarding these screenings are provided at the time that the dates and locations of the Health Fair are announced.