Transcription
AFL HOTEL & RESTAURANT WORKERS HEALTH & WELFARE TRUST FUND(RETIREES)Comprehensive Medical Plan Document (Self-Funded)Effective April 1, 1997SECTION 1DEFINITIONSIn accordance with all applicable policies of the AFL Hotel & Restaurant WorkersHealth & Welfare Trust Fund, the Participant and any Dependents listed on the enrollmentcard or added thereto, are entitled to medical, surgical, hospital and other benefitsaccording to the terms, conditions and limitations set forth in this Plan.When used in this Plan, in the Trust Fund’s enrollment card and in any supplementsto this Plan:1.1 "Beneficiary" means any Participant or Dependent covered by this Plan.1.2 "Calendar Year" means the period beginning January 1 and endingDecember 31 of any year. The first Calendar Year for a new Beneficiaryshall begin on that Beneficiary's Effective Date and end December 31 of thesame year.1.3 "Child" means the Participant's:(a)natural child;(b)adopted child or child placed in the home in anticipation of adoption;or(c)stepchild.1.4 “Claims Administrator” means that entity contracted by the Trust Fund toprocess and pay claims as provided under this Plan.1.5 "Clinical Laboratory" means a facility which:(a)is certified or licensed as a Clinical Laboratory by the propergovernmental authority;(b)meets the requirements of the Federal Medicare program; and(c)is approved by the Claims Administrator.1.6 “Clinical Social Worker” means a person licensed in the practice of socialworker and certified in clinical social work by a recognized nationalorganization.1.7 "Copayment" means a percentage of the Eligible Charge that is not paid as abenefit for covered services. The Beneficiary is solely responsible for payingthis amount to the provider of services.1.8 "Dentist" means a doctor of dentistry or dental surgery who is appropriatelylicensed to practice by the proper governmental authority and who rendersservices within the lawful scope of such license. A dentist is considered a"Physician" under this Plan, but only with respect to those Surgical Serviceswhich he or she is legally authorized to perform.1.9 "Dependent" means the Participant's Spouse and each eligible Child underEffective:Adopted:Updated:April 1, 1997July 24, 1998April 17, 2014Page 1AffordableCare 01/01Adopted:01/31/01
AFL Hotel & Restaurant Workers Health & Welfare Trust 171.18Effective:Adopted:Updated:26 years of age."Effective Date" means the date on which a person is accepted as aBeneficiary, as established and recorded by the Trust Fund, and is the date,subject to all applicable waiting periods provided under this Plan, on whichsuch Beneficiary's eligibility for benefits under this Plan begins."Eligible Charge" means the charge used to calculate the benefit payment fora covered service as determined by the Trust Fund according to the criteriain Section 3.7."Home Health Agency" means an agency which:(a)is certified or licensed as such by the proper governmental authority;(b)meets the requirements of the Federal Medicare Program; and(c)is approved by the Claims Administrator."Hospital" means any inpatient acute care institution (but does not includeany nursing or rest home, intermediate care facility, or Skilled NursingFacility) which:(a)is primarily engaged in providing facilities for surgery and for medicaldiagnosis and treatment of injured or ill persons by or under thesupervision of Physicians;(b)has registered nurses on duty;(c)is certified or licensed as a Hospital by the proper governmentalauthority; and(d)is recognized as a Hospital by the American Hospital Association.“Individually Identifiable Health Information” means information that eitheractually identifies the individual or creates a reasonable basis to believe thatthe information would identify the individual, as defined in 45 CFR §164.501."Injury" means an injury which results from an external force (such as a blow,collision, or impact) and which is of sufficient magnitude to require theservices of a Physician within 48 hours. Subjective symptoms which occurspontaneously or from trivial movement or exercise such as localized pain ofjoints, pain from nerves, disturbances of circulation, muscle pains and aches,or headaches and which are of physiological, pathological, toxic, or infectiveorigin are not to be considered the result of external force and therefore shallnot be considered an injury.“Marriage and Family Therapist” means an individual who is licensed in thepractice of marriage and family therapy practice.“Licensed Mental Health Counselor” means a person who engages in thepractice of mental health counseling and certified for alcohol dependence,drug dependence or mental illness."Participant" means the person who executes the enrollment card which mustbe accepted by the Trust Fund."Participating Provider" means a provider of services who agrees with theTrust Fund that his or her fee to a Beneficiary for a service covered by thisPlan shall not exceed the Eligible Charge for that service."Physician" means:(a)a doctor of medicine (M.D.); or(b)a doctor of osteopathy (D.O.); or(c)a doctor of podiatric medicine (D.P.M.); or(d)a doctor of optometry (O.D.)April 1, 1997July 24, 1998April 17, 2014Page 2AffordableCare dentincludes allchildrenunder /01/04Adopted:12/10/03
AFL Hotel & Restaurant Workers Health & Welfare Trust fective:Adopted:Updated:who is appropriately licensed to practice by the proper governmentalauthority, who is licensed to prescribe and administer prescription drugs andwho renders services within the lawful scope of such license."Plan" means this document.“Protected Health Information” means individually identifiable healthinformation that is transmitted or maintained by electronic media or istransmitted in any other form or medium, as defined in 45 CFR §164.501."Psychiatrist" means a doctor of medicine (M.D.):(a)who is certified by or has at least three (3) years of psychiatric trainingacceptable to the American Board of Psychiatry and Neurology;(b)who is appropriately licensed to practice by the proper governmentalauthority and who renders services within the lawful scope of suchlicense; and(c)whose practice is limited solely to psychiatry or psychiatry andneurology."Psychologist" means a person who is appropriately certified or licensed toprovide psychodiagnostic or psychotherapeutic services by the propergovernmental authority and who renders services within the lawful scope ofsuch certificate or license."Registered Bed Patient" means a Beneficiary who has been admitted to aHospital or Skilled Nursing Facility upon the recommendation of a Physicianfor any Injury or illness covered by this Plan and who is registered by theHospital or Skilled Nursing Facility as an inpatient."Skilled Nursing Facility" means an inpatient care facility which:(a)is certified or licensed as such by the proper governmental authority;(b)meets the requirements of the Federal Medicare Program; and(c)is approved by the Claims Administrator."Spouse" means a person who is lawfully married to the Participant and isqualified as a Spouse in accordance with the Internal Revenue Code."Surgical Services" means professional services necessarily and directlyperformed by a Physician in the treatment of an Injury or illness requiringcutting; suturing; diagnostic and therapeutic endoscopic procedures;debridement of wounds including burns; surgical management or reduction offractures and dislocations; orthopedic casting; manipulation of joints undergeneral anesthesia; or destruction of localized surface lesions bychemotherapy (excluding silver nitrate), cryotherapy, or electrosurgery."Trust Fund" means the AFL Hotel & Restaurant Workers Health & WelfareTrust Fund or its designated representative.April 1, 1997July 24, 1998April 17, 2014Page 3Effective:04/14/03Adopted:03/12/03
AFL Hotel & Restaurant Workers Health & Welfare Trust FundRetireesSECTION 2ELIGIBILITY AND :Coverage under this Plan is available only to those individuals determined tobe eligible by the Trust Fund. Enrollment hereunder shall cease upontermination of eligibility or termination of the Plan.The Participant, Participant's Spouse and each of the Participant's Childrenunder 26 years of age are eligible for coverage under this Plan. Coverage isavailable to a child without regard to marital status, dependency upon aparent (or anyone else) for financial support, residency with a parent, or fulltime student status. A child’s own spouse and child do not qualify forcoverage. The Participant must enroll a Dependent with the Trust Fundwithin 30 days of the date of eligibility. If a Dependent is not enrolled within30 days of the date of eligibility, he or she may be enrolled only at the nextopen enrollment period, which is held once a year. However, if a Dependentwho is covered under a plan other than the Trust Fund subsequently losescoverage under that plan, such Dependent need not wait until the next openenrollment period but must enroll within 30 days of the loss of coverageunder that plan. Failure to enroll within this 30-day period will result in theDependent having to wait until the next open enrollment period.Coverage under this Plan shall cease upon the earliest of the followingevents:(a)For the Participant - upon the Participant's termination of eligibility,(b)For the Participant's Spouse - upon the Participant's termination ofcoverage or upon the dissolution of the marriage,(c)For the Participant's Children - upon the Participant's termination ofcoverage, or when a Child reaches 26 years of age prior thereto,unless such Child meets the provisions of Section 2.4 below.If a Child, upon reaching 26 years of age, is incapable of self-sustainingemployment because of a mental or physical disability which was incurredprior to age 19, is primarily dependent upon the Participant for support andmaintenance, and is unmarried, the Child shall be allowed continuedcoverage under this Plan so long as the Child continues to be soincapacitated, dependent, and unmarried. The Participant must furnishwritten evidence of such incapacity, dependency, and marital status to theTrust Fund within 31 days of the Child’s reaching 26 years of age, and at anytime thereafter upon request by the Trust Fund. The Child's coverage shallterminate when the Participant's coverage terminates or when the Childmarries or is no longer incapacitated and dependent.The Participant shall inform the Trust Fund, in writing, if a Dependent ceasesto be eligible for benefits on or before the first day of the month following themonth in which eligibility ceased. If the Participant fails to inform the TrustFund of the Dependent's ineligibility, and the Plan makes payments forservices to the ineligible Dependent, the Participant shall reimburse the Planfor the amount of such payments and any legal expenses to recover suchpayments. If proceedings to adopt a Child are not successful, the Participantshall notify the Trust Fund within 21 days. Coverage for such Child shallApril 1, 1997July 24, 1998April 17, 2014Page 4AffordableCare dentincludes allchildrenunder 26Effective:01/01/14Adopted:10/01/13AffordableCare e ActEffective:01/01/11Adopted:04/13/11
AFL Hotel & Restaurant Workers Health & Welfare Trust FundRetirees2.6Effective:Adopted:Updated:terminate as of the first day of the month following the date of notification orthe date when notification should have been given.Coverage for the Participant and any Dependents initially listed on theapplication card shall begin as of the Participant's Effective Date, providedthat proper documentation is received, if the Trust Fund has accepted theParticipant's application by giving written notice to the Participant of his or herEffective Date. By submitting the application card, the Participant alsoaccepts and agrees to be bound by the provisions of the Plan as now in forceand as hereafter amended.April 1, 1997July 24, 1998April 17, 2014Page 5
AFL Hotel & Restaurant Workers Health & Welfare Trust FundRetireesSECTION 3CLAIM AND PAYMENT FOR SERVICES3.13.23.3Effective:Adopted:Updated:Only services provided by Clinical Laboratories, Home Health Agencies,Hospitals, Physicians (M.D., D.O., or D.P.M.), Psychiatrists, Psychologists,and Skilled Nursing Facilities who qualify as such under the requirements ofthe Federal Medicare Program, are certified or licensed by the propergovernment authority, render services within the lawful scope of theirrespective licenses, and are approved by the Claims Administrator or TrustFund will be covered. Benefits may be available for services rendered byother providers as shown in specific sections of this Plan.Submission of Claim. No claim for services covered by this Plan will be paidunless it is supported by the provider's report regarding the servicesrendered. The Participant is responsible for ensuring that the providerfurnishes this report to the Claims Administrator, on the forms prescribed bythe Trust Fund, within one (1) year of the date the services are rendered.Payment for Services.(a)Participating Provider. When covered services are rendered by aParticipating Provider, the Plan will pay benefits directly to theParticipating Provider. Participating Providers have agreed to limittheir charges to Beneficiaries to not more than a specified amount. Inaddition, Participating Providers have agreed not to collect from anyBeneficiary an amount exceeding the Beneficiary's Copaymentspecified in this Plan, except for non-covered services.All claims for services rendered by a Veterans AdministrationMedical Center and/or Uniformed Military Services Facility will beadjudicated (processed) on a participating provider basis using thecomparable participating provider Eligible Charge, but in no eventshall the Fund pay the Veterans Administration Medical Center and/orUniformed Military Services Facility any differently than the Fund’sparticipating provider Eligible Charges, and payments are to be madedirectly to the Veterans Administration Medical Center and/orUniformed Military Services Facility.(b)Nonparticipating Provider. The Claims Administrator or Trust Fundhas no agreement with nonparticipating providers and they maycharge the Trust Fund's Beneficiaries more than the Eligible Chargefor any service. The Plan’s benefit payments for services rendered bynonparticipating providers will be a specified portion or percentage ofthe Eligible Charge for the service. For services by a nonparticipatingprovider, the benefit level may be a lower percentage of the EligibleCharge than the Plan would pay to a Participating Provider. TheBeneficiary is responsible for paying the specified Copayment plusany amount of the provider's charge which exceeds the EligibleCharge. Payment of claims for services covered by this Plan andrendered by a nonparticipating provider:(i)are not assignable;(ii)shall be made by the Plan, in its sole discretion, directly to theApril 1, 1997July 24, 1998April 17, 2014Page 6Effective:01/01/05Adopted:09/20/07
AFL Hotel & Restaurant Workers Health & Welfare Trust Participant or to the Dependent or, in the case of theParticipant's death, to his or her executor, administrator,provider, Spouse, or relative; and(iii)shall in no event exceed the amount which the Plan would payto a comparable Participating Provider for the same servicesrendered.Reimbursement for Services. If a Beneficiary has paid for services coveredby this Plan, the Participant will be reimbursed in accordance with the termsof this Plan. To receive payment for such services, a Participant must submita claim within one (1) year after the last day on which such services wererendered.Late Claims. No payment will be made on any claim submitted to the ClaimsAdministrator or Trust Fund more than one (1) year after the last day onwhich the services were rendered unless it shall be shown to the satisfactionof the Trust Fund that there was unusual and justifiable cause for such latesubmission.Medical Necessity of Services. This Plan covers only medically necessaryservices; the Plan will not cover any unnecessary services nor will theunnecessary portion of any charge be paid. The fact that a Physician mayprescribe, order, recommend, or approve a service does not in itselfconstitute medical necessity or make a charge an allowable expense underthis Plan. A Beneficiary may ask a Physician to write to the ClaimsAdministrator for a determination regarding the medical necessity of a servicebefore it is performed. The Claims Administrator will determine the medicalnecessity of the test or treatment. To be considered medically necessary, aservice must meet all of the following criteria:(a)The service or treatment must follow standard medical practice and beessential and appropriate for the diagnosis or treatment of an illnessor Injury. Standard medical practice, with respect to a particularillness or Injury, means that the service was given in accordance withgenerally accepted principles of medical practice in the United Statesat the time furnished.(b)The service or treatment must not be "experimental" (e.g., used inresearch or on animals) or "investigative" (e.g., used only on a limitednumber of people or where the long-term effectiveness of thetreatment has not been proven in scientific, controlled settings, and,where applicable, has not been approved by the appropriategovernment agency).(c)If there is more than one (1) medically appropriate method of treatinga Beneficiary, the Plan’s benefit will be based on the least expensivemethod, even if the health care provider elects to treat the Beneficiaryby a more expensive method. Similarly, if the services could beprovided in more than one (1) type of facility or setting (e.g., Hospitalor Physician's office), the Plan’s benefits will be based on the leastexpensive facility or setting.(d)The service or treatment is being covered by the U.S. Department ofHealth HCFA Medicare Coverage Issues Guidelines.Eligible Charges. The Plan’s benefit payments and the Beneficiary'sApril 1, 1997July 24, 1998April 17, 2014Page 7
AFL Hotel & Restaurant Workers Health & Welfare Trust payments for services are based on the Eligible Charges for the services(i.e., the Beneficiary pays a specified percentage or portion of the EligibleCharge for each service). The Plan will not pay the portion of any chargethat exceeds the Eligible Charge. General excise or other tax is not includedin the Eligible Charge. A Beneficiary is responsible for paying all taxes.(a)Definition.(i)The charge for a covered service made by a ParticipatingProvider will be considered eligible when it complies with thefee schedule established by the Trust Fund and the provisionscontained in the agreement between the Claims Administratorand such Participating Provider.(ii)The Eligible Charge for a covered service made by anonparticipating provider who is a Physician, Psychiatrist,Psychologist, or Clinical Laboratory will be the lowest of thefollowing two (2) charges:a.the charge established by the Trust Fund, orb.the actual charge for the service.(iii)The Eligible Charge for a covered service rendered by anonparticipating facility that is a Hospital, Skilled NursingFacility, ambulatory surgical center, birthing center, HomeHealth Agency, or other similar facility will be the lowest of thefollowing two (2) charges:a.the charge established by the Trust Fund, orb.the actual charge for the service.(b)Claims for Services Provided by Out-of-State Providers. Benefitpayments for covered services rendered outside the State of Hawaiishall not exceed 150% of Eligible Charges for the same orcomparable services rendered in the State of Hawaii. Priorauthorization is required prior to receiving non-emergency servicesoutside the State of Hawaii as provided in Section 5, Managed CareProgram.Qualified Medical Child Support Orders. Any claim for benefits with respectto a Child covered by a Qualified Medical Child Support Order ("QMCSO")may be made by the Child or by the Child's custodial parent orcourt-appointed guardian. Any benefits otherwise payable to the Participantwith respect to any such claim shall be payable to the Child's custodial parentor court-appointed guardian.Review of Claims. The Trust Fund shall have discretionary authority todetermine all questions of eligibility of Beneficiaries, to determine the amountand type of benefits payable to any Beneficiary or provider in accordancewith the terms of this Plan, and related regulations, and to interpret theprovisions of this Plan, as is necessary to determine benefits.Claims and Appeals Procedures.(a)Designation of an Authorized Representative. The Beneficiary maydesignate another person to act on the Beneficiary’s behalf in thehandling of benefits claims as the Beneficiary’s authorizedrepresentative. In order for the Beneficiary to designate anotherindividual to be an authorized representative, the Beneficiary mustApril 1, 1997July 24, 1998April 17, 2014Page 03Adopted:12/11/02
AFL Hotel & Restaurant Workers Health & Welfare Trust FundRetirees(b)Effective:Adopted:Updated:April 1, 1997July 24, 1998April 17, 2014complete and file a form with the Claims Administrator. If theBeneficiary designates an authorized representative to act on theBeneficiary’s behalf, all correspondence and benefit determinationswill be directed to the authorized representative, unless theBeneficiary directs otherwise. The Plan will also provide informationto both the Beneficiary and the Beneficiary’s authorizedrepresentative, if so requested. In the case of a claim for urgent care,where the Beneficiary is unable to act on his or her own behalf, thePlan will recognize a health care professional with knowledge of aBeneficiary’s medical condition as the Beneficiary’s authorizedrepresentative. A health care professional is a physician or otherhealth care professional who is licensed, accredited, or certified toperform specified health services consistent with State law.Initial Claims. Upon the filing of a claim for reimbursement of benefits,the Plan must make a decision on the claim within the following timeperiods:(i)Urgent Care Claims. Any claim for urgent care must bedetermined within 72 hours of its receipt. The Plan may orallynotify the Beneficiary of the determination, but must provide awritten notice within three (3) days following the oralnotification. If the Beneficiary’s claim is improperly filed orincomplete, the Plan must provide notice to the Beneficiaryorally, or written if requested, within 24 hours of the date theclaim was received. The notification will indicate what theproper claims filing procedures are or what information needsto be provided to complete the claim. Once the informationhas been provided, the determination should be made within48 hours from the earlier of: 1) the time the Plan receives thenecessary information from the Beneficiary; or 2) the expirationof the 48-hour period provided to the Beneficiary to submit thenecessary information.A claim will be regarded as an “urgent care” claim if anyone of the following circumstances exist: 1) where failure toprovide the service could seriously jeopardize the Beneficiary’slife, health, or ability to regain maximum functions, or couldsubject the Beneficiary to serious pain that could not bemanaged without the requested care; or 2) where failure toprovide the requested care, in a physician’s opinion withknowledge of the Beneficiary’s medical condition, wouldsubject the Beneficiary to serious pain that could not bemanaged without the requested care; or 3) if the Beneficiary’streating physician deems it as urgent; or 4) if the Plan, inapplying the judgment of a “prudent layperson who possessesan average knowledge of health and medicine,” determines theclaim to be one involving urgent care.(ii)Pre-Service Claims. Any claim involving a requirement orrequest for approval prior to service being rendered must beprocessed within fifteen (15) days from the receipt of the claim.Page 9Effective:01/01/03Adopted:12/11/02
AFL Hotel & Restaurant Workers Health & Welfare Trust il 1, 1997July 24, 1998April 17, 2014This includes pre-authorizations and utilization reviews. If theclaim is improperly filed, the Plan must provide notice to theBeneficiary orally, or written if requested, within five (5) days ofthe date the claim was received. The notification will indicatewhat the proper procedures are for filing claims. The Plan mayextend the time to respond to the Beneficiary by fifteen (15)days, if circumstances exist beyond the Plan’s control thatinterfere with the timely determination of the claim, or ifinformation necessary to complete the claim is missing. ThePlan must provide a notice of extension to the Beneficiarywhich must state the circumstances which provide the basis forthe extension, and the date the Plan expects to render adecision. The Plan must provide notice prior to the extensionperiod taking effect. The Beneficiary must be given at leastforty-five (45) days from the date notification of the missinginformation is received to provide such information.Post-Service Claims. Any claim submitted after services havebeen performed will be determined within 30 days of receipt.The Plan may extend the time to respond to the Beneficiary byfifteen (15) days, if circumstances exist beyond the Plan’scontrol that interfere with the timely determination of the claim,or if information necessary to complete the claim is missing.The Plan must provide a notice of extension to the Beneficiarywhich must state the circumstances which provide the basis forthe extension, and the date the Plan expects to render adecision. The Plan must provide notice prior to the extensionperiod taking effect. The Beneficiary must be given at leastforty-five (45) days from the date notification of the missinginformation is received to provide such information.Concurrent Claims. If a Beneficiary is receiving ongoingtreatment under the Plan, the Plan must provide advancenotice of any determination to terminate or reduce theBeneficiary’s treatment. The Plan must provide notice to theBeneficiary sufficiently in advance to allow the Beneficiary toappeal the determination and render a decision prior to anyreduction or termination of the Beneficiary’s treatmentoccurring. Any claim a Beneficiary makes which involves bothurgent care and a continuing course of treatment previouslyapproved by the Plan, must be decided as soon as possible,given the urgency of the medical conditions involved. The Planmust provide the Beneficiary with notice of the claim’sdetermination within 24 hours of its receipt, if the claim wasreceived at least 24 hours prior to the expiration of theBeneficiary’s treatment. If the Beneficiary’s claim was receivedless than 24 hours prior to the expiration of treatment, the Planmust provide notification of its decision to the Beneficiary within72 hours of the receipt of the claim.Page 10Effective:01/01/03Adopted:12/11/02
AFL Hotel & Restaurant Workers Health & Welfare Trust il 1, 1997July 24, 1998April 17, 2014Notice of Initial Benefit Determination. When the Plan makes anadverse benefit determination, the Plan must give the Beneficiarywritten notice of the determination. The Claims Administrator musttake appropriate measures to ensure actual receipt of the notice bythe Beneficiary, and inform the Beneficiary of the significance of thenotice and the right to receive the notice free of charge. The Planmust also provide the Beneficiary with the notice, free of charge, uponthe Beneficiary’s request. The notice must be in plain language andinclude the following information:(i)the specific reason(s) for the adverse benefit determination;(ii)references to specific plan provisions on which thedetermination was based;(ii)a description of any additional information or information that isneeded for the Beneficiary to perfect the claim, and anexplanation of why the information is necessary;(iv)a description of the plan’s review procedures and the timelimits that apply to such procedures as well as a statementabout the Beneficiary’s right to bring a civil action underSection 502(a) of ERISA following an adverse benefitdetermination on review;(v)a statement that an explanation of the scientific or clinicaljudgment for the determination, which specifically applies theterms of the plan to the Beneficiary’s medical circumstances,will be provided free of charge upon the Beneficiary’s request,for determinations involving medical necessity or exclusions forexperimental treatment, or other similar exclusion or limit;(vi)the identification of any specific rule, guideline, protocol, orother similar criterion relied upon in making the determination,and a statement that a copy of such rule, guideline, protocol, orother similar criterion will be provided to the Beneficiary free ofcharge, upon the Beneficiary’s request; and(vii) a description of the expedited review process if the claim is anurgent care claim.Appeal of Claims. Any determination that a benefit is unnecessary orotherwise not payable shall be reviewed at the Beneficiary’s requestby the Benefits and Appeals Committee that is appointed andapproved by the Trust Fund. The Beneficiary must submit a writtenrequest for review unless the claim is one involving urgent care
Health & Welfare Trust Fund, the Participant and any Dependents listed on the enrollment card or added thereto, are entitled to medical, surgical, hospital and other benefits according to the terms, conditions and limitations set forth in this Plan. When used in this Plan, in the Trust Fund's enrollment card and in any supplements
