*** NOTE *** ALL services subject to deductible, unless otherwise noted.
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1 MEDICAL BENEFITS Fund Name: International Association of Machinists Motor City Revised: 3/14/18 MP Fund ID: 2800 SPD Version: 10/2004 Who is covered? Actives, Retirees, & their Dependents Tax ID: HAP PO Box Detroit, MI Fund Office Member Services Motor City Machinists PO Box 1438 Troy, MI *** NOTE *** ALL services subject to deductible, unless otherwise noted. Hines & Associates Pre-certification ***If class code begins with H, their claims are paid by HAP. All benefit questions are also handled by HAP for class code beginning with H *** ** NOTE ** Out of network ancillary charges, such as ER Physician, lab tests, anesthesiologist, etc. performed at a par facility are to be paid at the in-network level of benefits *Our system will be compliant to the ICD-10 coding requirements effective October 1, 2015* PAGE # IN NETWORK OUT OF NETWORK COMMENTS 42 PPO NETWORK HAP 54 AM DEDUCTIBLE ACTIVES $250 ind / $500 fam $250 ind / $750 fam 4 th quarter carry-over DEDUCTIBLE MEMBERS WITH CLASS CODES: AP1 ; AP2 ; AP3 $500 ind / $1,000 fam $500 ind / $1,500 fam 4 th quarter carry-over 58 DEDUCTIBLE RETIREES $200 per person 4 th quarter carry-over 42 OUT OF POCKET $2,000 individual $4,000 family 7 DEPENDENT AGE LIMIT Dependents covered up to age TIMELY FILING LIMIT One year from DOS 10 AUTHORIZED PROVIDERS MD, DO, DMD, DDS, DPM, DC No OOP max Out of network benefits never paid at 100%
2 90 (1,2,3 4), 93 Abortions ( Elective) Accident Work related MVA Reminder: If third party liability possible, we will require a signed lien & police rpt. Other 80% 50% 91 (23) Acupuncture Allergy Services 80 (2) Testing 80% 50% Injections 80% 50% Ambulance 80 (3) Ground 80% 50% Air 80% 50% 50 Appeal Procedures One Level Appeal Process 92 (35) Birth Control 100% Based on PPACA 66,80 Blood 80% 50% Chiropractic Services Maximum benefit $120 per calendar year **Hot & Cold packs may not be covered when billed with manipulations** 56,83 Visits 100% / $10 max 100% / $10 max Max 12 visits per calendar year X-Rays 50% 50%
3 39,94 COB Medicare Mandatory? Standard Coordination of Benefits Yes Follows plan guidelines 56,71 Consultations 100% / $15 copay 50% Court Ordered Tx 68 Dental Surgery 80% 50% Must prove medical necessity 55,72 Diagnostic X-rays/Labs (DXL) 80% 50% 80 (9) Durable Medical Equipment (DME) 80% 50% Prosthetic Bras 80% 50% Repairs must be pre-approved Preferred provider Americare prosthetic bras covered per year after mastectomy Breast Pump 80% 50% Covers one, SINGLE electric pump 92 (39) Education/Counseling Emergency Care 56 ER: Accident 100% / $50 copay 100% / $50 copay ER: Illness 100% / $50 copay 100% / $50 copay Physician 80% 50% Copay waived if admitted Urgent Care 80% 50% 55,73 Extended Care Facility (same as SNF) 80% 50% Max 120 days per calendar year
4 Foot Care Exam 80% 50% 80, 81 (13) Surgery 80% 50% Testing 80% 50% Orthotics 80% 50% Preferred provider Americare Growth Hormones 91 (25) Hearing Aids Preferred provider Americare ,74 Home Health Care 80% 50% Max 130 visits per calendar year. In absence of HHC agency in the area, RN or LPN will be covered up to $50 per day 30 visits per year 76 Hospice Care 80% 50% Hospitalization Maximum Period 6 months R&B 80% 50% Average semi-private room rate Ancillary 80% 50% 55,66 Pre-cert? Yes, through Hines & Associates ICU/CCU 80% 50% Physician 80% 50%
5 91 (19, 28) Infertility 55,80 Injections 80% 50% 55,72 Lab Tests 80% 50% Maternity Pre & Post Natal Visits 100% 50% Based on PPACA Delivery 80% 50% 67, 93 (48) Newborn Care 80% 50% Birthing Center 80% 50% Midwife 80% 50% 91 (15) Mental Health Dependent Daughter? Inpatient 80% 50% Outpatient 100% / $15 copay 50% 91 (22) Obesity Surgery for Obesity and Weight Loss 56 Office Visits 100% / $15 copay 50% 91 (21) Pain Management Penile Implants
6 80 (4) Private Duty Nursing 80% 50% Preferred provider Americare (10) Prosthetics 80% 50% Preferred provider Americare Routine / Preventative Wigs Covered with cancer dx Adult Well Exam 100% 50% Well Child 100% 50% Mammograms (includes 3D) 100% 50% 56, 82 Pap Smears 100% 50% Based on PPACA Prostate 100% 50% DXL 100% 50% Immunizations 100% 50% 55, 73 Skilled Nursing Facility (same as ECF) 80% 50% Max 120 days per calendar year 91 (23) Smoking Cessation 100% Based on PPACA Sterilization 9, 91 (24) Voluntary 100% - Women 80% - Men 50% Based on PPACA Reversal
7 91 (16) Substance Abuse Treatment Inpatient 80% 50% Outpatient 100% / $15 copay 50% 80 (8) Supplies 80% 50% Preferred provider Americare Surgery Inpatient 80% 50% Outpatient 80% 50% All Elective procedures which could be considered cosmetic such as: Vein Surgery Blepharoplasty Breast Reductions MUST BE REVIEWED FOR MEDICAL NECESSITY 55, 69 Office 80% 50% Assistant 80% 50% Anesthesia 80% 50% CRNA 80% 50% Second Opinion 80% 50% ASC 80% 50% Multiple Surgeries Refraction Eye Surgery *Multiple surgeries are reviewed and may be reduced* (Full/Half/Half)
8 Therapy Physical 80% 50% Occupational Speech 80% 50% 80, (14) Vision Radiation 80% 50% Chemotherapy 80% 50% Hemodialysis 80% 50% Cardiac Rehab 80% 50% 56, 82 TMJ 80% 50% MUST pre-approve Transplant Services Organ 80% 50% 70 Bone Marrow 80% 50% Donee 80% 50% Covered only if Covered Person of Fund 55, 72 X-Ray 80% 50%
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