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UFCW LOCAL 1776 and
PARTICIPATING EMPLOYERS HEALTH and WELFARE FUND |
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| You Need Medical Care | |
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Each family member selects his/her own primary care physician. Referred care You go to your PCP who will provide care or, when appropriate, give you a written referral for care. This offers: 
PCP guidance and coordination of care. No deductible or coinsurance other than a $15 co-payment for routine office visits and other applicable
co-payments for other services referred by your PCP. In most cases, no claim forms to file. Unlimited lifetime maximum benefits. Pre-certification is handled by your participating doctor.
If you receive care from your PCP or a provider referred by your PCP, most services are covered 100% after a small co-payment for some services. Choosing your PCP If you enroll in the KPOS Program, you choose your PCP from a directory of network doctors and hospitals. This directory will be provided to you automatically without charge. Each member of your family may choose a different PCP. Your PCP must be your first contact for all non-emergency care and for referrals to specialists, if you want the maximum benefits available. However, a female participant or eligible dependent may use any participating obstetrician/gynecologist without a referral from her PCP. Self-referred care If you go directly to a doctor or hospital without a referral from your PCP, this will be treated as self-referred care. Under self-referred care, the following guidelines apply: No PCP guidance or coordination of care. A $500 per person ($1,500 per family) annual deductible. A coinsurance payment by you of 20% of the reasonable and customary amount
for most services after payment of the deductible. Requires submitting claim forms. A lifetime benefit maximum of $1,000,000. Possible balance bills for amounts above the reasonable and customary amount, if you use a
non-participating provider. You are required to handle pre-certification.If you receive self-referred care, you have to pay a deductible each calendar year before the KPOS Program will start paying benefits. Once you have met the deductible for the calendar year, the KPOS Program will generally pay 80% of the reasonable and customary amount for services that the KPOS Program determines are medically necessary. You pay the remaining balance of the reasonable and customary amount (called your coinsurance). In addition to the deductible and coinsurance amounts, you are responsible for any amounts in excess of the reasonable and customary amount, if you use a non-participating provider. In an emergency If you need immediate emergency medical care for a condition that is life threatening or potentially disabling, you should immediately get the care you need. The KPOS Program will always pay 100% for a medical emergency requiring hospitalization. There is a $35 co-payment for treatment in a hospital, which is waived if you are admitted, or a $15 co-payment if you are treated at your PCP’s office. A medical emergency is generally defined as a sickness or injury of such a nature that failure to get immediate treatment could put the health of the covered person, or with respect to a covered pregnant female, the health of the pregnant female or her unborn child, in serious jeopardy or cause serious harm to bodily functions or serious dysfunction of any bodily organ or part. Some examples of medical emergencies include apparent heart attack, severe bleeding, loss of consciousness, and severe or multiple injuries. Customer Service The KPOS Program provides a customer service line. Through a toll-free number, service representatives can provide information and other services you need to make the most of your benefits.
Your Share Of The Expense - Co-payments, Deductibles And Coinsurance Referred care You must pay a small amount, called your co-payment, when you receive some referred services. For example, you pay $15 when you go to your PCP's office for a visit ($25 for a visit to a specialist). However, there is an annual limit to the amount you pay out-of-pocket for co-payments ($1,000 per person, $2,000 per family). If you can demonstrate that you have reached the annual limit, you may apply for reimbursement for any additional co-payments for referred care during that calendar year. Self-referred care Self-referred routine adult physical are not covered. No referral from your PCP is necessary for routine gynecology or maternity care when services are performed by a KPOS participating obstetrician. Each year, before the KPOS Program pays any self-referred benefits, you pay a specified amount of your covered expenses (called your deductible). Your deductible is $500 per person or $1,500 per family. No more than three times the individual deductible under one family coverage must be satisfied in each benefit period. This means that as soon as members of your family incur the $1,500 family deductible amount, the deductible obligation is met for the remainder of the benefit period for all family members. However, no family members may contribute more than the individual deductible amount to the overall family deductible). Once you have met your deductible, the KPOS Program pays a specified percentage of your self-referred expenses and you pay the remaining amount (called your coinsurance). When you use a self-referred provider (either a participating provider without a referral from your PCP or a non-participating provider), the KPOS Program generally pays 80% of the reasonable and customary amount for medically necessary services (as determined by the KPOS Program). You are responsible for paying the difference, usually 20%.You are also responsible for all amounts above the reasonable and customary amount if you use a non-participating provider. Expenses above the reasonable and customary amount will not be applied to satisfy your out-pocket-limit (discussed below). The KPOS Program further protects you from costly medical expenses. There is a limit to the amount of covered medical expenses you pay out of your own pocket in any given year. You pay your required coinsurance amounts for self-referred care until you reach this out-of-pocket limit. Then, the KPOS Program will pay 100% of the reasonable and customary amount for services for the rest of that year. For example, based on the chart below, after you have incurred out-of-pocket costs (coinsurance) for self-referred services in the amount of $2,500, the KPOS Program will pay 100% of the reasonable and customary amount for medically necessary services (as determined by the KPOS Program) for the remainder of that year. However, you will still be responsible for all expenses above the reasonable and customary amount if you use a non-participating provider. Out-of-Pocket Limit for Self-Referred Care ------------------------------------------------------------ Individual $2,500 ================================= Family $7,500* =================================
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In meeting the family out-of-pocket limit, not more than three times the
individual out-of-pocket limit must be satisfied by the members enrolled under
one family coverage before the co-insurance is increased to 100% for covered
services for the remainder of the benefit period. However, no family member may contribute more
than one individual amount of out-of-pocket limit toward the family out-of-pocket
limit. |