Overview of Health Benefits

The Funds provide benefits for medically necessary medical, hospital and other healthcare services, including prescription drugs. Benefits may vary slightly, depending upon the plan to which the beneficiary belongs. Provisions for covered services include:

• Physician services and other primary care
• Preventive care
• Treatment of illness and injuries
• Treatment of mental illnesses
• Surgery
• Inpatient hospital services
• Outpatient hospital services
• Skilled nursing facilities
• Home health services and equipment
• Durable medical equipment and supplies
• Oxygen
• Obstetrical and family planning care
  

The Funds and Medicare

About 85% of Funds beneficiaries are enrolled in Medicare. If a beneficiary is Medicare-eligible they must elect to take the Medicare Part B entitlement (Medical Insurance) and pay the monthly premiums in order to keep the Funds’ health services card. The Funds will not provide health benefits for otherwise eligible beneficiaries who are not enrolled in Medicare. Through a contractual arrangement with the Center for Medicare and Medicaid Services (CMS - formerly HCFA), the Funds is the primary payer for Medicare Part B services if there is no other insurance that may be primary. The Funds also pays for some of the expenses Medicare does not pay. For example, the Funds pay Medicare co-payments, coinsurance and deductibles for the beneficiary.

For Medicare Part A (Hospital Insurance) covered services for Medicare enrolled beneficiaries, Medicare is the primary payer. This means that the Medicare intermediary pays the Part A covered benefits first.

Medicare Part D is the newest part of the Medicare program. It provides Medicare beneficiaries with prescription drug coverage. Funds’ Medicare eligible beneficiaries do not need to sign up for Medicare Part D because the prescription drug coverage under the Funds’ Health Benefit Plans is better than Medicare’s drug plan, and the Funds’ Plans do not charge a monthly premium.

Beneficiaries should contact the Call Center for questions about Medicare and the Funds: 1-800-291-1425.

The Funds and the Department of Labor Black Lung Program

The Federal Black Lung program is a workers compensation program for individuals with a condition attributable to lung diseases and conditions caused by coal mining. Some Funds' beneficiaries have medical coverage under the Black Lung program. These beneficiaries' claims may be paid by the Funds, Department of Labor (DOL) or Responsible Mine Operator (RMO), depending upon the service and DOL beneficiary assignment.

Beneficiaries should contact the Call Center for questions about Medicare and the Black Lung Program: 1-800-291-1425.