Article III - Eligibility
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UMWA Health and Retirement Funds

Article III - Eligibility

A. HEALTH BENEFITS
(10) GENERAL PROVISIONS
 
· Acceptance of Plan by providers, 28
 
· Bonus, health care, 93‑031
 
· Coordination of benefits/copayment, 60
     ‑‑copayment fro spouse with coverage from employer, 98-017  
 
· Cost containment, 88‑024, 88‑253
     ‑‑formulary drug program with surcharge, 98-013 , 98-014, 02-002 CA-056, CA-072
     ‑‑hospital admission precertification, 84‑196, 88‑253
     ‑‑implementation of network pharmacy program, 88‑322, 88‑403, 88‑411
     ‑‑maintenance drug mail order program, CA-066
     ‑‑second surgical opinion, 88‑253
 
· Excessive charges, 254
 
· Health maintenance organization (HMO), 81‑411, 81‑533, 88‑302
 
· Hold harmless provision, 88‑609, 88‑667
     ‑‑beneficiary signs contract of adhesion, 84‑531
     ‑‑deductible-must meet for hold harmless, 93-105
     ‑‑excessive charges, 84‑260, 84‑264, 84‑412, 84‑484, 84‑583, 88‑076, 98-048CA-040
     ‑‑promulgation of rules, 84‑264, 84‑484, 84‑702, 88‑076, 88‑253, 88‑452, 88‑505, 88‑508, 88‑558, 88‑667
     ‑‑reimbursement of beneficiary’s payment, 84‑264, 84‑484, 88‑105, 88‑335
     ‑‑services not provided under Plan, 84‑467, 84‑602
 
· Medicare, 102, 81‑044
     ‑‑active employee over age 65, 20
     ‑‑beneficiary receives SSDI benefits, 88-650, CA-071
     ‑‑bonus, health care, 93‑031
     ‑‑enrollment in Part D, 02-029, 02-030, 02-031, 02-033, CA-076, CA-077, CA-078, CA-079, 07-0021
     ‑‑notification of obligation to enroll in Part A & B, 84‑448, 84‑491, 84‑516, 84‑679
     ‑‑spouse fails to enroll Medicare Part B, 84‑637, 02-026
 
· Non‑duplication, 78, 81‑411, 81‑462, 81‑496, 84‑128, 88‑063, 88‑141
     ‑‑copayment for spouse with coverage from employer, 98-017
     ‑‑individual insurance policy, 88‑369
     ‑‑Medicare, CA‑031
     ‑‑spouse’s employer offers coverage, 88‑132, 88‑496, CA-074 
 
· Notice of coverage termination, 84‑440, 84‑606, 88‑674, CA-047 
 
· Preferred Provider List (PPL), 93‑035, CA-062 
 
· Promulgation of rules, 81‑155, 81‑593, 84‑042, 84‑196
     ‑‑alcoholism and drug rehabilitation program, 88-847 
     ‑‑claims reimbursement procedures, 132, 88‑440
     ‑‑drug utilization, 88‑411, 88‑414, 88‑571
     ‑‑employment status questionnaire, 88‑113CA-047 
     ‑‑enrollment Medicare Part D, 02-02902-03002-031CA-076CA-077CA-078CA-07907-0021
     ‑‑formulary drug program with surcharge , 98-013, 98-014, 02-002 CA-056CA-072 
     ‑‑generic vs. brand name drugs, 88‑403, 93‑079CA-072
     ‑‑hold harmless procedures, 84‑264, 84‑484, 88‑076
     ‑‑mail order, 88‑613, 93‑029, CA-066, 02-00102-003
     ‑‑prescription drug reimbursement procedures, 84‑04288-322, 88‑403, 88‑411, 88‑414, 88‑571, 88‑613
     ‑‑time limit on claims submission, 337, 81‑697, 81‑710, 88‑645, 11-0027
 
· Subrogation, 84‑252, 84‑565, 88‑141, 88‑369
‑‑auto insurance, 93-104, 98-049
‑‑cases covered by workers’ compensation laws, 88‑055, 88‑525, 88‑678