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Benefits
The Funds provides comprehensive healthcare benefits, including prescription drugs, to Funds' beneficiaries. Benefits may vary slightly, depending upon the plan to which the beneficiary belongs. Most beneficiaries are covered by the Funds' Combined Benefit Fund, with the remainder covered by the 1992 Benefit Plan or 1993 Benefit Plan. To read the details of the individual fund, please click here and select the Fund name.
- Medicare and Non-Medicare Eligible Beneficiaries
- About 85% of Funds beneficiaries are eligible for Medicare enrollment. For Medicare enrolled beneficiaries, Medicare is the primary payer for Medicare Part A services. This means that the Medicare intermediary pays the Part A covered benefits first. 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 pays Medicare co-payments, coinsurance and deductibles for the beneficiary. Also, Medicare only pays for a limited number of prescription drugs, but the Funds does provide medically necessary prescription drug coverage for all eligible Funds' beneficiaries.
About 15% of Funds beneficiaries are not enrolled in Medicare. The Funds coverage is primary for these beneficiaries, unless the beneficiary has other health insurance that is primary to the Funds. These individuals receive the same level of benefits coverage as the Medicare beneficiaries, but the Funds is responsible for the cost of care.
- Medical Necessity
- The Funds pays only for medical and prescription services that are medically necessary.
- Payment Levels
- Hold Harmless Provision
- Some healthcare providers are not willing to accept the Medicare level of payment for their services. If a provider attempts to collect a balance denied by the Funds as exceeding the fee level or as not medically necessary, the Funds will protect the beneficiary from paying the balance. Beneficiaries are advised not to pay these "balance bills." Beneficiaries should not send balance bills to the Funds. Instead, beneficiaries should call the Call Center or their local Field Service Office and notify them if they receive a balance due notice, a collection letter, or any legal or credit action taken against them. The Funds will step in and help resolve the situation. A list of phone numbers follows:
| Field Service Office |
Telephone Number |
| The Call Center |
1-800-291-1425 |
| Washington, PA |
1-724-229-5401 |
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