Fund Annual Summary
Notice of Privacy Practices
Women's Health & Cancer Rights
Summary Of Material Modifications
When Your Life Changes
(Medicare Part D) Creditable Notice
(Medicare Part D) Creditable Notice - Bronze Plan
Participant Links
 
Quick Links
 
Contact Us
Site Map
 
 

 

Summary of Material Modifications (SMM)

 

 

 

Effective January 1, 2019:

Physical/Occupational Therapy Benefit Increase - ALL PLANS

Effective 1/1/19, the maximum number of Physical/Occupational Therapy visits has been increased from 30 visits per person/per calendar year to 36 visits per person/ per calendar year. Physical/Occupational Therapy no longer requires pre-certification. 

Psychiatric Plan Exclusion — ALL PLANS

Effective 1/1/19, the following language will be added to the Plan Exclusion list, which is found in all metallic plans Sections (Platinum Plus, Platinum Essential, Gold, Silver, Bronze and Bronze Essential) of the Summary Plan Description:

"Psychiatric treatment for a condition that is not a mental condition; residential care or other custodial care; and services and/or programs that are not medically necessary to treat a mental condition. For example: services that are performed in educational, vocational, or recreational settings; and "outward bound-type," "wilderness," "camp," or "ranch" programs.""

Effective July 1, 2019:

 

Eligibility of Disabled Dependents Who Have Turned 26 Years Old — ALL PLANS

Continued eligibility for disabled dependents beyond the last day of the month in which the dependent reached age 26 will no longer apply. All eligible dependent children will cease to be eligible for health insurance effective on the last day of the month in which the child turns age 26.

Eligibility for health insurance will remain unchanged for all dependent children including disabled dependent children that have turned ape 26 BEFORE 7/1/19 and had been previously determined to be disabled and eligible for continued health coverage. Disabled dependent children who turn age 26 AFTER 7/1/19 will no longer be eligible for health insurance.

Effective September 1, 2018:

 

Ambulance — Air and Sea — ALL PLANS

The Fund will now consider Air and Sea Ambulance Services as an eligible benefit. As such, the following will now be added to the Schedule of Benefits, which is found in all metallic plans Sections (Platinum Plus, Platinum Essential, Gold, Silver, Bronze and Bronze Essential) of the Summary Plan Description:

2.15       Ambulance — Air or Sea Transportation: Benefits are provided for professional ambulance service by air or sea of any type, to the hospital or from one hospital to another in connection with an inpatient admission or emergency outpatient treatment immediately following an accident or illness. Services deemed to be non-medically necessary or inappropriate will not be covered.

 

Ambulance — Air and Sea — ALL PLANS — Continuation

 

 

Outpatient/
Other Services

In Network

Out of Network

Out of Network
Annual
Deductible

PLATINUM Plus:

 

Ambulance — Air & Sea (see 2.15)

100% of the PPO rate

The lesser of 80% of the Fund's Allowed Eligible Amount or $20,471.

 

PLATINUM Essential:

 

Ambulance — Air & Sea (see 215)

90% of the PPO rate; subject to Deductible

The lesser of 75% of the Fund's Allowed Eligible Amount or $20,471; subject to Deductible

$400/Person $800/Family

GOLD:

 

Ambulance — Air & Sea (see 2.15)

90% of the PPO rate; subject to Deductible

The lesser of 70% of the Fund's Allowed Eligible Amount or $20,471; subject to Deductible

$1,200/Person $2,400/Family

SILVER:

 

Ambulance — Air & Sea (see 2.15)

80% of the PPO rate; subject to Deductible

The lesser of 60% of the Fund's Allowed Eligible Amount or $20,471; subject to Deductible

$2,000/Person $4,000/Family

BRONZE Plus:

 

Ambulance — Air & Sea (see 2.15)

70% of the PPO Rate;           subject to

Deductible

The lesser of 50% of the Fund's Allowed Eligible Amount or $20,471; subject to Deductible

$3,000/Person

BRONZE Essential:

 

Ambulance — Air & Sea (see 2.15)

70% of the PPO rate; subject to Deductible

The lesser of 50% of the Fund's Allowed Eligible Amount or $20,471; subject to Deductible

$5,000/Person

 

 

 

Effective July 23, 2019:  Gene Therapy— ALL PLANS

 

Effective 7/23/19, the following will be added to the Plan Exclusion list, which is found in all metallic plans Sections (Platinum, Gold, Silver and Bronze) of the Summary Plan Description:

 

"All Gene Therapy."

 

 

 

 

 

 

 

 

 

 



148-06 Hillside Avenue, Jamaica, NY 11435

(718) 291-3434 • webmaster

Copyright © 2008 All Rights Reserved. Privacy Policy