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FOR PARTICIPANTS WITH THE BASIC PLAN
The Affordable Care Act prohibits health plans from applying arbitrary dollar limits for coverage for key benefits. This year, if a plan applies a dollar limit on the coverage it provides for key benefits in a year, that limit must be at least $750,000.
Your health insurance coverage, offered by the NOITU Insurance Trust Fund, does not meet the minimum standards required by the Affordable Care Act described above. Instead, it put an annual limit of:
NOITU Insurance Trust Fund
Basic Plan
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Inpatient Services
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Benefits
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Acute Hospital Care
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100% of the PPO rate, or 100% of the Fund's allowed amount; subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year
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Alcohol & Substance Abuse Detox
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100% of the PPO rate, or 100% of the Fund's allowed amount; maximum of up to 5 days per person, per calendar year; subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year
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Maternity/ Birthing Centers
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100% of the PPO rate, or 100% of the Fund's allowed amount; subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year
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Maternity/ Nursery
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100% of the PPO rate, or 100% of the Fund's allowed amount; subject to the $35,000
Basic Plan aggregate maximum per person, per Calendar Year
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Mental Health Care
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100% of the PPO rate, or 100% of the Fund's allowed amount; maximum of 30 days per person, in a Calendar Year; subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year
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Outpatient/ Other Services
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Benefits
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Emergency Transportation
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Up to $500 maximum per trip; subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year
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Ambulatory Surgical Facility
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100% of the PPO rate, or 100% of the Fund's allowed amount; subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year
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Anesthesia
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Based on an allowance of up to $45 for each unit of anesthesia; subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year
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Blood & Plasma
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100% of PPO rate; or 100% of the Fund's allowed amount. A maximum of up to 10 pints per person per year; storage not covered; subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year
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Chemotherapy
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80% of the Fund's allowed amount, subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year. Drugs ancillary to the administration of chemotherapy agents are covered subject to the foregoing limitations
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Diagnostic Procedures (Surgical)
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80% of the Fund's allowed amount; subject to the maximum surgical allowance of $2,000 per person, per Calendar Year
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Durable, Medical Equipment
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80% of the Fund's allowed amount up to a maximum Benefit of $1500 per person, per Calendar Year; subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year
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Emergency Room
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If the visit constitutes “emergency care” pursuant to Section 2.10 of the Basic Plan, 100% of the PPO rate or 100% of the Fund's allowed amount; $50 Co-pay. If admitted, Co-pay is waived. Subject to $35,000 Basic Plan aggregate maximum per person per Calendar Year
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Home Health Care/ Home Infusion
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80% of the Fund's allowed amount; maximum of 100 visits commencing within 7 days of discharge (maximum of 40 visits if home care begins more than 7 days after discharge or there is no hospitalization), no more than a total of 100 visits per person, per Calendar Year; subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year. Home infusion is covered only as part of a home health care visit
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In-Hospital Doctor Consultation
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80% of the Fund's allowed amount; one consultation per specialty, per day; subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year
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In-Hospital Doctor Visits
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80% of the Fund's allowed amount; one visit from each provider, per day, subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year
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Interpretations of Diagnostic Tests
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30% of the Fund's allowed amount, payable at 80%; subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year. Only for inpatient and emergency room
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Kidney Dialysis
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80% of the Fund's allowed amount; subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year
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Midwives
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80% of the Fund's allowed amount; subject to the maximum surgical allowance of $2,000 per person, per Calendar Year
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Pre-surgical testing
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100% of the PPO rate, or 100% of the Fund's allowed amount; subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year
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Radiation Therapy
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80% of the Fund's allowed amount; subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year
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Surgery
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80% of the Fund's allowed amount , subject to the maximum surgical allowance of $2,000 per person, per Calendar Year
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Surgery (Assistant)
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20% of the Fund's allowed amount, subject to the maximum surgical allowance of $2,000 per person, per Calendar Year
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Surgery (Multiple Procedures)
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Eligible secondary procedures payable at 50% of the Fund's allowed amount, subject to the maximum surgical allowance of $2,000 per person, per Calendar Year
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Xray Interpretations
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30% of the Fund's allowed amount, payable at 80%; subject to the $35,000 Basic Plan aggregate maximum per person, per Calendar Year. Only for inpatient and emergency room
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Please be aware that not all of the following drug plans may pertain to you. It is important for you to refer to your enrollment documents (e.g. Summary Plan Description) for more information on your specific drug plan or you may contact the NOITU Insurance Trust Fund's Member Services Department at 718-291-3434, option 3.
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Prescription Drugs
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Benefits
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$10/$30 copay plan
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$3,000/$6,000 annual maximum
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$7.50/$20 copay plan
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$1,500/$3,000 annual maximum
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Rx $350/$700
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$350 maximum per individual per year with a $700 maximum for the family per year
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In order to apply the lower limits described above, your health plan requested a waiver of the requirement that coverage for key benefits be at least $750,000 this year. That waiver was granted by the U.S. Department of Health and Human Services based on your health plan’s representation that providing $750,000 in coverage for key benefits this year would result in a significant increase in your premiums or a significant decrease in your access to benefits. This waiver is valid for one year.
If the lower limits are a concern, there may be other options for health care coverage available to you and your family members. For more information, go to: www.HealthCare.gov.
If you have any questions or concerns about this notice, contact:
Daniel Lasky, Administrator
NOITU Insurance Trust Fund, 148-06 Hillside Avenue, Jamaica NY 11435
SI USTED NO HABLA INGLES, Si tiene dificultad de entender cualquier parte de este documento, llame a la oficina de 9:00a.m. a 5:00p.m., de lunes a viernes, (718) 291-3434, seleccione el numero #3, para ayudarle.
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