FILE: 78-099.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number 78-99 Subject: Home Health Services/Definition of "Intermittent" References:Amended 1950 & 1974 Benefit Plans and Trusts, Article III, Section A (6)(a) 2 Question: In order to qualify for home health services under the Plan, a "Beneficiary's medical condition must require skilled nursing care, physical therapy or speech therapy on an intermittent basis." What defines "an intermittent basis?" Answer: The Beneficiary who requires home health services on an intermittent basis will require such services at least once every 60 days. This may mean as much as a few hours a day, several times a week. Occasionally, a Beneficiary may require more service, e.g., 8 hours a day for 5 weeks for a short period of time when unusual circumstances exist. Examples of such "unusual circumstances" are: o the Beneficiary has just returned from the hospital and must be oriented, along with the family, to various aspects of home care; o the Beneficiary's condition is terminal; o the Beneficiary has suffered a relapse which, while requiring more intensive care, either does not necessitate institutionalization or institutionalization cannot be immediately arranged; or o the Beneficiary is very ill and requires extensive care and has no family members present during the day. FILE: 81-01.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-1 Subject: Drug Benefit References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III A (4) Question: What benefits for medications and drugs are provided for under the 1981 Coal Wage Agreement? Answer: Only prescription drugs (drugs which by state or federal law require a prescription in order to be dispensed by a licensed pharmacist) and insulin are covered benefits under the 1981 Coal Wage Agreement. FILE: 81-02.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-2 Subject: Coverage of Estrogens and Progestogens for medical Purposes References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III A (4) Question: Are estrogens or progestogens a covered benefit under the 1981 Coal Wage Agreement when they are prescribed for the treatment or control of an illness and are dispensed by a licensed pharmacist? Answer: Yes, if they are prescription drugs and prescribed by a physician. However, estrogens and/or progestogens prescribed for the purpose of birth control are specifically excluded from coverage under the provisions of the 1981 Coal Wage Agreement. FILE: 81-03.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-3 Subject: Coverage of Prescription Required Vitamins References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III A (4) Question: Are prescription only vitamins that are prescribed in the absence of an acute illness a covered benefit? Answer: Yes, but only if such vitamins require a prescription according to Federal or State Law in order to be dispensed by a licensed pharmacist. FILE: 81-04.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-4 Subject: Definition of Plan Administrator References:Amended 1950 & 1974 Benefit Plans & Trusts, Article I, Section (3) Question: Who are the Plan Administrators referred to in the 1950 and 1974 Benefit Plans? Answer: The Trustees of the Funds are the Plan Administrators for the 1950 and 1974 Benefit Plans. The Plan Administrator for health plans administered through the Employer to be determined by each Employer. FILE: 81-05.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-5 Subject: Interpretation of Level of Benefits Under the 1981 Coal Wage Agreement References: 1981 National Bituminous Coal Wage Agreement Question: Where it appears that there may be a discrepancy between the language of the 1978 Coal Wage Agreement and the language of the 1981 Coal Wage Agreement, may the Trustees interpret the 1981 Agreement as providing identical benefits under the 1978 Agreement? Answer: No, the 1981 Coal Wage Agreement is a separate document specifying defined benefits and must be interpreted separately. The Trustees must follow the language of the 1981 Coal Wage Agreement, whether or not the benefits coincide with the benefits under the 1978 Coal Wage Agreement. FILE: 81-06.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-6 Subject: Definition of Hospitalization Limitation for Mental Illness References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (1) (e) Question: The inpatient hospital benefit for mental illness limits the number of covered days as follows: Benefits are provided for up to a maximum of 30 days for a Beneficiary who is confined for mental illness in a hospital by a licensed psychiatrist. Subject to the approval by the Trustees, hospitalization may be extended for a maximum of 30 additional days for confinements for an acute (short-term) mental illness, per episode of acute illness. (More than 90 days of confinement for mental illness over a two-year period (dating from the first day of hospital confinement) is deemed for purposes of this Plan to be a chronic (long-term) mental problem for which the Trustees will not provide inpatient hospital benefits.) How is the limit of "90 days over a two-year period" to be interpreted? Answer: The limit refers to the cumulative number of days of inpatient hospital care for all mental illness diagnoses, without regard to each acute episode. The two-year period begins on the first day of an inpatient hospital stay for a mental problem and ends two full years later. FILE: 81-07.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-7 Subject: Confinement in a Residential Treatment Center for the Treatment of Mental Illness References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (1) (a) and (e) Question: Are benefits provided for the services rendered to a Beneficiary who, following an inpatient hospital confinement for mental illness, is admitted to a 24-hour, residential treatment center for the treatment of mental illness? Answer: No, such treatment is only a covered benefit if the institution satisfies the definition of an accredited hospital, and total treatment days over a two year period (dating from the first day of hospital confinement for a mental illness), do not exceed 90 days. FILE: 81-08.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-8 Subject: Lodging Costs for a Family Member's Stay References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (1) (a), A (7) (e), and A (11) (a) 9 Question: 1. Are benefits provided for hospital room and board costs resulting from a family member's stay with a hospitalized Beneficiary, when the attending physician considers the family member's stay to be medically necessary? 2. When a Beneficiary qualifies for travel benefits under Article III, Section A (7) (e) of the Plan, are benefits provided for lodging costs for the escort, when the attending physician considers the escort to be medically necessary? Answer: 1. No. 2. Yes, but only if the use of an escort has received the prior approval of the Plan Administrator. If the patient's length of stay at an out-of-area facility is so long that it would be impractical for the escort to remain until the patient can travel to his/her home, the escort will be reimbursed for the cost of two round trips. FILE: 81-09.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-9 Subject: Clarification of Outpatient Hospital Benefits References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (2) and A (3) Question: What benefits are provided for services rendered in an outpatient department of a hospital? Answer: Under Article III, Section A (2) of the Plan, the following general benefit categories are listed as covered: (a) Emergency Medical and Accident Cases (b) Surgical Cases (c) Laboratory Tests and X-rays (d) Chemotherapy and Radiation Therapy (e) Physiotherapy (f) Renal Dialysis In addition, the Plan provides benefits for other services rendered in an outpatient hospital setting: - Physician visits and primary care provided in a clinic, which includes the outpatient department of a hospital (as well as free-standing clinics) (see Section A (3) (h)); - Medical consultations without specification as to the setting (see Section A (3) (I)); - Podiatrist's services for minor surgical procedures or in accordance with Q&A #81-44, without specification as to the setting. Major podiatric surgery, however, must be rendered in an inpatient hospital setting and receive prior approval of the Trustees (see Section A (3) (n); - Primary medical care benefits, including immunization, allergy desensitization injections, and certain screening procedures, without specification as to the setting (see Section A (3) (o)); - Anesthesia services, when administered and billed by a physician, in surgical and obstetrical cases (see Section A (3) (d)); - Radiation therapy without specification as to setting when performed in conjunction with medical, surgical or obstetrical services if the physician performing the radiation therapy is not the same physician who performs the medical, surgical or obstetrical services (see Section A (3) (k)); - Chemotherapy, when provided for the treatment of a malignant disease and when prescribed and billed by a physician (See Section A (3) (K)); - Surgical services requiring prior approval without specification as to setting (see Section A (3) (f)); - Emergency medical treatment, provided such treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of an accident (see Section A (3)(i)); - Surgical services, including operative and cutting procedures, and usual and necessary post-operative care, for the treatment of illnesses, injuries, fractures or dislocations. Benefits are not provided for assistant surgeon's services when the Beneficiary is not an inpatient in a hospital (see Section A (3)(a),(b)). FILE: 81-10.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-10 Subject: Definition of Emergency Treatment Benefit References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (2) (a) and A (3) (i) Question: Benefits are provided for emergency medical treatment or medical treatment of an injury as the result of an accident, provided the treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of the accident. 1. Would emergency treatment for conditions such as the following be covered under this provision: - acute pain attributed to gout? - heart attack, severe chest pain, or congestive failure experienced by a patient with (chronic) heart disease? - intracranial bleeding or stroke experienced by a patient with hypertension? 2. Are benefits provided for inpatient and outpatient hospital and physicians' services following emergency treatment beyond the 48-hour initial care limit (for example, suture removal or cast removal)? Answer: 1. Yes, because the symptoms are acute and require emergency treatment, even though the underlying illness causing the symptoms may be chronic. 2. Yes, if the follow-up treatment is covered under the Plan. FILE: 81-11.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-11 Subject: Benefits for Treatment in a Non-Accredited Hospital References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (1) (a), A (1) (i) and A (2) (a) Question: Are benefits provided for treatment rendered in a non-accredited hospital? Answer: No, unless the hospital is approved by the Trustees. However, benefits are provided for emergency treatment on an outpatient basis under Section III A (2) (a) and III A (3) (i). FILE: 81-12.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-12 Subject: Physiotherapy References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (2) (e) Question: Under Article III A (2) (e) of the Plan, benefits are provided for physiotherapy treatment, if such treatments are prescribed and supervised by a physician. Does this mean that the therapy must be directly supervised by a physician? Answer: No. The original treatment plan for physiotherapy must be prescribed by a physician and, thereafter, supervised by him/her. Supervision does not require the actual presence of the physician during the administration of the therapy. FILE: 81-13.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-13 Subject: Outpatient Abortion References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (1) (h), A (2) (b) and A (3) (c) Question: Are benefits provided if the termination of a pregnancy is performed on an outpatient basis? Answer: Yes, if it is medically necessary and is performed by a licensed gynecologist or surgeon. FILE: 81-14.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-14 Subject: Cardiac Rehabilitation Programs in Outpatient Hospital Settings References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (2) (c) and A (3) (j) and (o) 4 Question: Are benefits provided if cardiac rehabilitation programs are conducted on an outpatient hospital basis? Answer: Yes. Benefits are provided for such programs if conducted in an outpatient hospital setting. This includes coverage for stress testing, other medically necessary tests and associated therapy performed as part of the rehabilitation program. However, benefits are only provided for those parts of the program that are conducted under a physician's direct supervision. FILE: 81-15.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-15 Subject: Dental and Oral Surgical Services References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (3) (e) Other: 1981 Contract Q&A #81-16 Question: Are the following dental and oral surgical procedures covered under the Plan: a. extraction of teeth? b. gingevectomy, alveolectomy, operculectomy? c. gingivoplasty, alveoplasty, vestibuloplasty? d. treatment for abscessed teeth? e. resection of prognathic mandible? f. mandibular bone staple? g. orthodontics? Answer: The dental and oral surgical procedures listed above, when performed in a hospital, are covered only when they are part of a treatment for an illness or injury which is otherwise a covered benefit. Examples of this would be: (1) the extraction of teeth during emergency treatment of extensive facial damage resulting from an auto accident; (2) the extraction of teeth during treatment of cancers of the head and mouth; and (3) the insertion of a mandibular bone staple to repair a fractured jaw. Except as provided in the above paragraph, none of these seven procedures is covered under the Plan. FILE: 81-16.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-16 Subject: Hospitalization and Professional Services for Dental Procedures References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (1), A (3)(d) and (e) and A (11) 19 Question: 1. Is oral surgery a covered benefit? 2. Are dental services a covered benefit? 3. Are hospitalization charges for semi-private room and board related to a non-covered dental procedure covered under the Plan? 4. Are benefits provided for the medically necessary services (enumerated in Article III, Section A (1), (2) and (3)) in connection with hospitalization for a non-covered dental procedure? 5. Are benefits provided for physician services (enumerated in Article III, Section A (3)) in connection with a hospitalization for a non- covered dental procedure? Answer: 1. Yes, if such surgery receives the prior approval of the Plan Admini- strator and is performed in a hospital and hospitalization is medically necessary, benefits are provided for oral surgery treating * tumors of the jaw * fractures of the jaw, including reduction and wiring * fractures of the facial bones * frenulectomy, when related to ankyloglossia * temporomandibular joint dysfunction, only when medically necessary and related to an oral orthopedic problem. * biopsy of lesions of the oral cavity 2. No. 3 & 4. No, except when, 1) hospitalization is medically necessary because of pre-existing medical condition, and 2) prior authorization has been obtained from the Plan Administrator. 5. No, except for the treatment of a medical condition for which benefits would otherwise be provided. FILE: 81-17.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-17 Subject: Trench Mouth References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (3) (h) and (11) (a) 19 Question: Are benefits provided for the treatment of trench mouth when performed by the following: 1. A physician? 2. A dentist? Answer: 1. Yes, because treatment of illness by a licensed physician is a covered benefit. 2. No. FILE: 81-18.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-18 Subject: Obturators References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (7) (a) 1 Question: Is an obturator used to close the opening of a surgical defect following the excision of a cystic tumor of the maxilla a covered benefit? Answer: Yes. FILE: 81-19.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-19 Subject: Coverage of Organ Donors and Recipients References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (1) (a) and A (3) (a) and (f) Question: 1. If a Beneficiary must receive a transplanted organ, will benefits be provided for medical and/or surgical fees for both the recipient and the donor? What if the donor is not covered by the Plan? 2. Will benefits be provided if a Beneficiary donates an organ to a recipient not covered by the Plan? Answer: 1. Yes, if the transplant is medically necessary. Medical or surgical fees directly related to the donation of an organ by a non-covered patient will be considered part of the surgical fees of the entire operation and will be covered by the Plan. 2. Yes. Benefits will be provided for medical and/or surgical fees for the donor for an organ donation to a non-covered patient if the organ donor is a Beneficiary and neither the recipient's insurance coverage nor any special programs cover the cost of hospitalization, surgery and related expenses. All organ transplant procedures must receive prior approval of the Plan Administrator. FILE: 81-20.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-20 Subject: Surgical Treatment of Obesity References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (3) (f) and A (11) (a) 25 Question: What conditions must be satisfied for the Plan Administrator to approve gastric or intestinal bypass surgery for the treatment of obesity? Answer: Benefits are only provided for these two surgical procedures when all of the following conditions are satisfied: 1. The Beneficiary has a pathological, morbid form of severe obesity (two or more times the desirable weight); 2. other, more conservative therapies have been tried and proved unsuccessful; and 3. prior approval has been obtained from the Plan Administrator. FILE: 81-21.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-21 Subject: Downs Syndrome and Mental Retardation References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A, (1) (a); A (2) (a); A (3) (a), (b), (d), (e), (f), (g), (i), (o); A (6) (a) (b) (c); A (7) and A (11) (a) 8, 17 and 19 Question: A beneficiary has Downs Syndrome which includes mild mental retardation, cleft lip and cleft palate. Does the Plan provide the following services: 1. Surgical repair of the cleft lip and palate? 2. Speech therapy after surgery? 3. a) Homemakers' services to allow the child to remain with his/ her natural parents? b) Intermittent skilled nursing visits to the home for the purpose of parent training, post-surgical skilled home nursing care and patient evaluation? For a beneficiary who is moderately retarded, does the Plan provide the following services: 4. An appendectomy? 5. Treatment of pneumonia? 6. Diagnostic, evaluation and psychological testing? 7. Full mouth extractions required because of rampant caries? 8. Prolonged hospitalization when the parents refuse to accept discharge home after surgery or other procedure requiring hospitalization, and no placement alternative exists? Answer: 1. Yes, under Surgical benefits. 2. Yes, under the Home Health & Speech Therapy benefits. 3. a) No, custodial care is specifically excluded from coverage. b) Yes, under the Home Health benefits. 4. Yes, under the Inpatient Hospital and Physicians' Services benefit. 5. Yes, under the Physicians' Services benefit. 6. Yes, under the Outpatient Mental Health benefit. 7. No, since dental services (except as listed in Section A (3) (e)) are excluded from coverage. 8. No, since custodial care and unnecessary hospitalization are excluded from coverage. FILE: 81-22.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-22 Subject: Physical Examinations References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (3) (o) 1 and 3; Section A (3) (p) 10 Other: 1981 Contract Q&A #23 Question: 1. A family or individual wishes to establish a relationship with a physician before anyone is actually sick. The physician (general practitioner, internist, pediatrician) requires new patients to have a physical examination before accepting them as regular patients. Does the Plan cover such physical examinations? 2. A physical examination is required by a school board before a child can enter the school system. Does the Plan cover such physical examinations? 3. A physician requires periodic examinations of newborn babies. Does the Plan cover such physical examinations? Answer: 1. No. The Plan only provides benefits for a physical examination when that examination is certified as medically necessary by a physician according to one of the following criteria: a. The Beneficiary has an existing medical condition under treatment by a physician, or b. The Beneficiary has attained age 55, or c. The Beneficiary is undergoing an annual or semi-annual routine examination by a gynecologist, or d. The Beneficiary is undergoing a routine examination prescribed by a specialist as part of such specialist's care of a medical condition. 2. No. Benefits are not provided for physical examinations performed solely to satisfy the school board's requirements. 3. Yes. Benefits are provided for care of newborn babies and routine medical care of children prior to attaining age 6. FILE: 81-23.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-23 Subject: Medical Care for Children References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (3) (o) (1) Question: According to the Plans, benefits are provided for the routine medical care of children prior to attaining age 6. Are benefits provided for medical care of a child after attaining the age of 6? Answer: Yes, as long as the medical care is covered under the Plans as a benefit for all eligible Beneficiaries. FILE: 81-24.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-24 Subject: Endoscopic Procedures References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (1) (a), A (3) (j) and A (3) (p) 10 Question: Are endoscopic procedures, such as gastroscopy, sigmoidoscopy, and proctoscopy, covered under the Plan? Answer: Yes, but only if the endoscopic procedures are ordered by a physician, are performed to diagnose or treat a definite condition, illness or injury and are medically necessary. FILE: 81-25.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-25 Subject: Blood Gas Studies References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (3) (j) Question: Are benefits provided for blood gas studies if they are not ordered by a physician? Answer: No. Under the Plan, laboratory tests are covered only when they are ordered by a physician. FILE: 81-26.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-26 Subject: Chiropractic Care and Services References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (3) (p) (1) Question: 1. Are benefits provided for chiropractic care? 2. Are benefits provided for medical supplies billed by a chiropractor? Answer: 1. No, Chiropractic care is a Medicare-covered but not a Funds covered benefit. However, for Funds Medicare enrolled beneficiaries the Funds will pay the Medicare covered portion of chiropractic charges. For Funds non-Medicare beneficiaries no coverage will be provided for chiropractic care. 2. No. FILE: 81-27.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-27 Subject: Diagnostic Studies for Infertility References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (3) (j) Question: Are benefits provided for diagnostic tests to determine infertility? Answer: Yes, if such tests are ordered by a physician and are considered medically necessary by the physician. FILE: 81-28.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-28 Subject: Surgical Revision of Scars Caused by Disease References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (3) (a) and (p) 9 Question: Are benefits provided for surgery or the revision of scars caused by disease? Answer: No. Cosmetic surgery, unless pertaining to surgical scars or to correct the results of an accidental injury or birth defect, is excluded from coverage. FILE: 81-29.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-29 Subject: Prescription Drugs Dispensed in a Physician's Office, Nursing Home or Clinic References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (4) and A (5) (a) 5 Question: Are prescription drugs dispensed in each of the following settings covered under the Plan? 1. A physician operates a pharmacy in his office and he employs a full time licensed pharmacist to dispense drugs that the physician prescribes. The pharmacy is licensed with the State Pharmacy Board. 2. A nursing home owns and operates a pharmacy located within the nursing dispensed by a state licensed pharmacist for Beneficiaries who are home facilities. The pharmacy is state licensed and the drugs are not confined in the nursing home. 3. An organized clinic which is state licensed (or is recognized as a clinic by the Trustees) employs a state licensed pharmacist who packages and dispenses its drugs. The clinic itself is not licensed as a pharmacy. 4. A physician prescribes, fills, and dispenses drugs from his office, which is not licensed as a pharmacy. Answer: Only prescription drugs dispensed by a state licensed pharmacist are covered under the Plan. Therefore, benefits would be provided for prescription drugs dispensed in settings, 1, 2, and 3, but excluded in setting 4. FILE: 81-30.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-30 Subject: Take-Home Drugs References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (1) (a), A (4) (a), and A (8) (b) Other: 1981 Contract Q&A #29 Question: 1. Are benefits provided for take-home prescription drugs following confinement in a nursing home or hospital? 2. If so, are they subject to copayment? Answer: 1. Yes, but only when dispensed by a state licensed pharmacist. 2. Yes. FILE: 81-31.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-31 Subject: Drugs Furnished to Patients Receiving Nursing Care References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (4), A (5) (a) 5, A (6) (c) and A (8) (b) Question: 1a. Are benefits provided for prescription drugs furnished to Beneficiaries receiving skilled nursing care in a nursing care facility? b Are they subject to copayment? 2a. Are benefits provided for prescription drugs furnished to Beneficiaries receiving custodial or intermediate care in a nursing care facility or receiving skilled nursing care at home? b. Are they subject to copayment? Answer: 1a. Yes. b. No. 2a. Yes. b. Yes. FILE: 81-32.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-32 Subject: Administration of Prescription Drugs References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (3) (h), A (4) (b) 3, and A (8) (a) Other: 1981 Contract Q&A #29 Question: Are prescription drugs that are administered in a physician's office subject to copayment? Answer: Yes, in the case of administration of a medication implies that the taking of the medication must be managed or that the medication must be applied by a physician (or by someone under a physician's supervision), necessitating a visit to the physician's office. The medication and the administration of it together make up the cost of a single visit, and the visit is subject to a single copayment. No, in the case of dispensing of medications from a physician's office implies that the medication can be taken without being managed or applied by a physician, i.e., that it is given out to the patient at the physician's office. Examples of medication dispensed in a physician's office are pain killers or samples given to a patient (after treatment or consultation) for short-term, immediate use. The Funds will not pay for medications dispensed in a physician's office as they are excluded under the Plan. FILE: 81-33.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-33 Subject: Injections Administered by Non-Health Professional References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (3) (p) 8 Question: Are benefits provided for the administration of injections by a person who is not a licensed health professional? Example: A relative or friend administers insulin injections to a diabetic in the diabetic's home. Answer: No. FILE: 81-34.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-34 Subject: Drug Supplies References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (4) (a) Question: Does the Plan expressly limit the initial prescription of a covered drug to a 30 day supply, the first refill to a 60 day supply, and the second refill to a 90 day supply? Answer: Yes. FILE: 81-35.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-35 Subject: Drugs Administered in an Out-patient Department or Emergency Room References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (2) (a), A (e) (i), and A (4) Question: Are benefits provided for the administration and cost of medication provided in conjunction with treatment received in an outpatient department or emergency room of a hospital? Answer: Yes. Take home drugs, however, are not a covered benefit. FILE: 81-36.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-36 Subject: Home Health Service Treatment Plan References:Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (6) (a) (3) Question: Under the Home Health Services and Equipment benefit, the physician must initiate a plan of treatment. When must this plan of treatment be initiated in order for payment for Home Health Services to be made? Answer: Payment will be made for home health therapy or care only if the physician has issued instructions reduced to writing to the Home Health Agency before the actual home health therapy or care begins. FILE: 81-37.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-37 Subject: Home Health Services References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (6) (a) 4 Question: Under the Home Health Services benefit, it is stated that "services must be provided by a certified home health agency". If there are no certified home health agencies near the Beneficiary's home, may home health services be provided directly by a registered nurse, home health aide or therapist? Answer: Yes. The Plan Administrator may determine that a certified home health agency is not available, (i.e., not present), or not accessible to the Beneficiary, i.e., cannot be used by the Beneficiary for reasons including but not limited to: the agency is already operating at full capacity and cannot accept new patients; the Beneficiary does not live within the agency's service area; or geographic constraints make it too difficult for agency personnel to travel to the Beneficiary's home. In such cases, the Plan Administrator may authorize an independent registered nurse, home health aide or therapist to provide home health services to the Beneficiary according to the attending physician's written instructions. FILE: 81-38.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-38 Subject: Medical Equipment and Supplies References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (6) (d) and (e), and A (7) (a) and (d) Question: What medical equipment and supplies are covered under the Plan? Answer: A. Under the Home Health Services and Equipment provision, benefits are provided for the rental and, where appropriate as determined by the Plan Administrator, purchase of medical equipment and supplies (including items essential to the effective use of the equipment) suitable for home use when determined to be medically necessary by a physician. These supplies and equipment include, but are not limited to, the following: 1. Durable Medical Equipment (DME) which (a) can withstand use (i.e., could normally be rented), (b) is primarily and customarily used to service a medical purpose, (c) generally is not useful to a person in the absence of an illness or injury, and (d) is appropriate for use in the home. Examples of covered DME items are canes, commodes and other safety bathroom equipment, home dialysis equipment, hospital beds and mattresses, iron lungs, orthopedic frames and traction devices, oxygen tents, patient lifts, respirators, vaporizers, walkers and wheel chairs. 2. Medical supplies necessary to maintain homebound or bedridden Beneficiaries. Examples of covered supplies are enema supplies, disposable sheets and pads (also called "Chux" or "blue pads"), supplies for home management of open or draining wounds, heating pads (for therapeutic use only) and insulin needles and syringes. 3. Oxygen, as specified in Article III, Section A (6) (e). B. Under the Other Benefits provision, benefits are provided for the following: 1. Orthopedic and prosthetic devices prescribed by a physician when medically necessary, including items necessary for their effective use. These include, but are not limited to, the following items: - prosthetic devices, replacing internal or external body parts (other than dental), such as cardiac pacemakers, maxillofacial devices and devices replacing all of the ear or nose, and waste collection and retention devices for incontinent people (e.g., catheters, ostomy bags and supplies: - prosthesis following breast removal, including surgical brassieres - leg, arm, back and neck braces - trusses - stump stockings and harnesses (see Article III Section A (7) (a) 5) - surgical stockings (see 1981 Contract Q&A #46) - orthopedic shoes and corrections (see Article III Section A (7) (a) 7 and 8) 2. Hearing aids (see Article III Section A (7) (d)). C. Items of a convenience nature or those that do not require professional judgement, recommendations or instructions to purchase or use are not covered benefits. Examples of such items are: ordinary support (panty) hose, garter belts, disposable paper cups or towels, cotton balls, cotton swabs, bandaids, exercise equipment, and foot pads for bunions or calluses. Covered items under A and B above are not subject to copayment. FILE: 81-39.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-39 Subject: Inhalation Therapy References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (5) (a) (3) and (6) (e) Question: Under Home Health Services and Equipment provision, benefits are provided for the services of inhalation therapists in the home with the attending physician's order. Are inhalation therapists' services covered in any other setting? Answer: Yes, inhalation therapists' services are covered (with the attending physician's order) when rendered in a hospital, skilled nursing facility, clinic or other treatment center. FILE: 81-40.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-40 Subject: Social Work References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (3) (o) 4 and A (7) (f) Question: Are benefits provided for treatment rendered by a social worker? Answer: Yes, under the following circumstances: 1. The social worker is licensed, when required by state law. If state law does not require licensure, then certification by the ACSW is required; 2. The treatment is determined by a physician to be medically necessary; 3. The treatment provided by the social worker fits into any of the following categories: psychotherapy, psychological testing, counseling, group therapy (other than encounter or self-improvement therapy) and Plan Administrator approved alcoholism or drug rehabilitation programs; 4. The treatment is rendered under the direct supervision of a physician and 5. Free care sources are not available. Benefits are not provided for: 1. Encounter and self-improvement group therapy; 2. Custodial care related to mental retardation and other mental deficiencies; 3. Treatment of school-related behavioral problems; 4. Services by private teachers; 5. Alcoholism and drug rehabilitation if an advance determination has not been made by the rehabilitation team that the Beneficiary is a good candidate for rehabilitation; 6. Alcoholism and drug rehabilitation programs that do not have prior approval of the Plan Administrator. FILE: 81-41.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-41 Subject: Rehabilitation Therapy References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (6) (a) and (b), and A (7) (b) and (c) Question: 1. Are benefits provided for rehabilitation therapy rendered in the Beneficiary's home if the Beneficiary is a stroke patient and needs special instruction to restore the abilities needed to perform the activities of daily living (e.g., feeding, bathing, etc)? 2. Are benefits provided for rehabilitation therapy if the therapy means vocational training? Answer: 1. Yes. Since benefits are provided for physical and speech therapy services at home when prescribed by a physician to restore functions lost or reduced by illness or injury, benefits are also provided for rehabilitation therapy when the therapy is provided for these same purposes. Such therapy must be prescribed and supervised by a physician, administered by a licensed therapist and approved by the Plan Administrator. 2. No. FILE: 81-42.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- CONTROL NUMBER 81-42 SUBJECT: Biofeedback Therapy REFERENCES: Amended 1950 & 1974 Benefit Plans & Trusts Article III, Sections A (7) (f) and A (11) 24 QUESTION: Are benefits provided for biofeedback therapy? ANSWER: Biofeedback Therapy is generally a non-covered benefit. It may be covered, however, when prescribed by a physician as reasonable and necessary for an individual patient for muscle re.education of specific muscle groups, for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm or weakness, and only when more conventional treatments (such as heat, cold massage, exercise, support) have been attempted and have not been successful. Payment for Biofeedback Therapy, when covered, will be made only to a physician, clinic or hospital. FILE: 81-43.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-43 Subject: Routine Foot Care References: Amended=1950 & 1974 Benefit Plans & Trusts, Article III, Section A (3) (m) and (n) Under the Podiatrist's Services benefit, benefits are provided for the following services when rendered by a qualified licensed podiatrist: (1) Minor surgery (2) Major surgery when performed in a hospital after prior approval has been received from the Plan Administrator. Routine care of the feet such as trimming of nails, treatment of corns, bunions (except capsular or bone and surgery therefor) and calluses is expressly excluded. Question: 1. Are benefits provided for routine foot care when a Beneficiary has diabetes, peripheral vascular disease or peripheral neuropathy of the foot? 2. Are benefits provided for non-routine podiatric services rendered for treatment of such problems as tendinitis, ruptured Achilles tendon, and gout covered benefits? 3. Are benefits provided for diagnostic studies (i.e., laboratory tests and x-ray) ordered or performed by a qualified licensed podiatrist in conjunction with minor or major surgery or treatment of a non-routine foot problem? Answer: 1, 2, & 3. Yes. FILE: 81-44.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-44 Subject: Osteotomy of the Foot References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (3) (a) and (n) Question: Are benefits provided for osteotomy of the foot? Answer: Yes. Osteotomy, or bone cutting, of the foot, when performed by a licensed podiatrist may be covered either on an outpatient basis, when considered minor surgery, or an inpatient basis, when considered major surgery, depending on the type of osteotomy performed and where on the foot it is performed. When considered major surgery, the procedure must receive the prior approval of the Plan Administrator. Osteotomy of the foot is also covered, either on an inpatient or outpatient basis, when performed by a physician. When performed by a physician, no prior authorization is required. FILE: 81-45.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-45 Subject: Orthotic Construction References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (7) (a) 7 and 8 Question: Are benefits provided for orthotic constructions?* *Orthotic construction: orthotic appliance or apparatus used to support, align, prevent or correct deformities or to improve the movable parts of the body. Answer: Yes, when specifically prescribed by a physician or licensed podiatrist. If orthopedic corrections are made to ordinary shoes, only the corrections shall be paid for by the Plans. Benefits are not provided for footpads, stock orthotics or orthotic constructions for recreational purposes. A diagnosis must, therefore, accompany a bill for an orthotic construction. FILE: 81-46.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-46 Subject: Definition of Surgical Support Stockings References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (7) (a) 6 Question: 1. Are surgical stockings a covered benefit? 2. What are the guidelines for identifying surgical stockings? Answer: 1. Yes, but only when prescribed by a physician for surgical or medical conditions. 2. Surgical support stockings (Jobst, Ted, Horn, antiembolism stockings or comparable stockings in function and quality) are prescribed by a physician for medical conditions, such as thrombophlebitis, and/or conditions resulting from surgery such as vein ligation. Prescriptions must state diagnosis, patient's leg measurements and description of stocking. Example: above-knee length, below knee, toe out, etc. The brand name of the surgical stockings is the criterion that determines if the stockings are covered. The name indicated on the invoice is checked against a list of brand name stockings that are covered. Ordinary support hose are considered wearing apparel and are not covered under the Plan. Example: Support hose, panty hose. This benefit is subject to a limitation of a maximum of two pairs per prescription with no refills. FILE: 81-47.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-47 Subject: Penile Prosthesis References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (7) Question: Are benefits provided for the implantation of a penile prosthesis as treatment for sexual impotency? Answer: No, except when the implantation of the penile prosthesis is 1) prescribed by a surgical specialist, and 2) considered to be medically necessary because of an underlying medical condition (such as diabetes mellitus), rather than a psychological condition. FILE: 81-48.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-48 Subject: Drugs, Vitamins, Medical Equipment and Supplies Prescribed During Pregnanacy References:Pregnanacy Discrimination Act of 1978; Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (4) and A (6) (d) Question: Are benefits provided for drugs, vitamins, medical equipment or medical supplies prescribed for pregnancy-related conditions? Answer: Yes, but only to the extent that such benefits are provided under the Plan for other disabling conditions. In addition benefits are only provided for drugs which by state or federal law require a prescription in order to be dispensed by a licensed pharmacist. FILE: 81-49.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-49 Subject: Birth Control Services and Devices References: Pregnanacy Discrimination Act of 1978; Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (3) (o) 9 Question: Are benefits provided for birth control services and devices? Answer: Benefits are only provided for physician services in connection with the prescription of oral contraceptives, the fitting of a diaphragm or the insertion or removal of an I.U.D. Birth control devices and medications are not covered under the Plan except as provided for in Q&A #81-2. FILE: 81-50.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-50 Subject: Definition of Physician Visit References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (3) (h), A (3) (o) 2 and 4, A (6) (a) and (b), and A (8) Question: 1. What is the definition of "physician visit"? 2. Is a "physician visit" subject to co-payment? 3. Is each visit to a physician's office subject to co-payment? Answer: 1. A "physician visit" is defined as follows: A face-to-face consultation for examination, diagnosis, treatment, or advice. It is a visit if the consultation described above is provided by a physician or by a nurse or other person acting under the physician's supervision. The term "Physician" includes osteopathic physicians as well as M.D.s, but it does not include chiropractors. Examples of a physician visit include, but are not limited to, the following: a. Inhospital physician's visits b. Home, clinic, and office visits c. Emergency treatment d. Visit for medical consultation e. Visit to specialist f. Visit to podiatrist g. Visit for primary medical care h. Pre- and post-natal visits, if the physician charges separately for such visits in addition to the charge for delivery i. Visit for outpatient mental health, alcoholism, and/or drug addiction 2. Yes. 3. No. It is not uncommon for a Beneficiary to visit a physician's office and not see the physician. If the services the Beneficiary is receiving are on-going and routine in nature and do not require the direct supervision of a physician, such services are not subject to copayment. Examples of these routine services include, but are not limited to, the following: Control No.: 81-50 Page 2 a. Administration of B-12 injections for pernicious anemia b. Administration of chemotherapy c. Administration of radiation therapy d. Administration of physical and speech therapy e. Administration of allergy desensitization therapy (including the cost of materials, e.g. allergens for desensitization) f. Blood pressure checks to monitor antihypertensive therapy FILE: 81-51.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-51 Subject: Copayment for Flat Rate Obstetrical Delivery Services and NeoNatal Care References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (3) (c) and (o) 1, A (8) (a) Other: 1981 Contract Q&A #50 Question: 1. Is a physician's flat rate charge for obstetrical delivery services (including pre- and post-natal care) subject to copayment? 2. Is a pediatrician's flat rate charge for neonatal care received in the hospital subject to copayment? Answer: 1. No. 2. Yes, each pediatrician's visit is subject to copayment. FILE: 81-52.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-52 Subject: Copayment for Laboratory and X-ray Services References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (3) (j) and A (8) (a) Other: 1981 Contract Q&A #50 Question: Are laboratory and x-ray services subject to copayment? Example 1: An independent provider of laboratory and x-ray services is used by physicians. The provider bills the Plan on a fee-for-service basis. Are the provider's services subject to copayment? Example 2: An outpatient department of a hospital bills the Plan for an emergency room visit. Although not indicated on the claim, the bill includes both hospital (emergency room) services and the attending physician's visit. The radiologist who takes and interprets x-rays ordered by the attending physician bills the Plan separately. Are the radiologist's services subject to copayment? Answer: No, the laboratory and x-ray services, including the diagnostic services of the clinical pathologists and radiologists, are not subject to copayment. Example 1: The laboratory and x-ray services are not subject to copayment, but the visits to the physician who ordered the lab's services are subject to copayment. Example 2: The emergency room visit is subject to copayment but the radiologist's services are not. FILE: 81-53.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-53 Subject: Copayment on Prescription Drugs and Refills References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (4) and A (8) (b) Question: Is each refill of an initial prescription subject to copayment? Answer: Yes, both initial prescriptions and refills are subject to copayment. For purposes of the copayment provision, a prescription is deemed to be each 30 days' supply or fraction thereof. FILE: 81-54.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-54 Subject: Copayment for Prescription Drugs for Which the Charge is Less than $5.00 References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (4) and A (8) (b) Question: How is the copayment applied and credited for a prescription drug for which the charge is $5.00 or less? Answer: If the Beneficiary has not yet reached the prescription drug copayment maximum, the Beneficiary is responsible for the payment of the total charge for the prescription. In order to credit the Beneficiary's copayment account, a receipt should be sent to the Funds. If the Beneficiary has reached his/her copayment maximum, the pharmacy should bill the Funds for the actual charge. FILE: 81-55.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-55 Subject: Copayment for Anesthesiologists' Services References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, A (1) (a), A (3) (d), and A (8) (a) Question: Are anesthesiologists' services subject to copayment? Answer: No. Anesthesiologists' services, whether in support of surgery (pre- and post-operative care, as well as anesthesia at the time of surgery) or as an independent procedure (e.g., nerve block for pain relief) are not subject to copayment. FILE: 81-56.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-56 Subject: Copayment for Home Health Nurse Visits References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (6) (c) and A (8) (a) Question: Are home health nurse visits to a Beneficiary's home subject to copayment? Answer: No. Home Health Services are not listed under Section A (8) (a) as a benefit which is subject to copayment. FILE: 81-57.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-57 Subject: Copayment for Surgery References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (2) (b), A (3) (a) and (b), and A (8) (a) Question: Is surgery performed either as an inpatient or on an outpatient basis at a hospital, or surgical center or office subject to copayment? Answer: Yes. FILE: 81-58.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-58 Subject: Copayment Maximum for Individuals Changing Status References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (8) Question: What is the annual copayment maximum for an individual who changes status (active to in-active, or vice versa) during the copayment year? Example 1: An Employee has paid $75 in copayments for physician visits and $30 in drug copayments; he retires. Example 2: An Employee has paid $120 in copayments for physician visits and $30 in drug copayments; he retires. Example 3: A Pensioner has paid $90 in copayments for physician visits and $30 in drug copayments; he returns to work in a classified job with a signatory employer. Answer: The individual must meet the copayment maximum for his current status before the Plan will make full payment for the services. The drug copayment maximum is the same for the working and non-working groups. Therefore, in each of the examples above, an additional $20 must be paid to satisfy the drug copayment maximum. Therefore, the Employee in Example 1 must pay an additional $25.00 to meet the $100 maximum for physician visits. For the Employee in Example 2, there is no refund of any money he may have paid in excess of the inactive non-working group's maximum. In Example 3, the Employee would have to pay an additional $60.00 to meet the $150 maximum for physician visits before the Employer could begin to pay the full charge for physician visits. FILE: 81-59.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-59 Subject: Copayment Maximum in Family with Two Primaries References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (8) Question: If a husband and wife are both primaries under the Plan, is the annual copayment maximum applicable twice for their family? Answer: No. Only one copayment maximum is applicable per family. FILE: 81-60.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-60 Subject: Copayment for Individuals Employed Under Different Agreements During One Copayment Year References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (8) Question: A signatory coal company hires an employee who has previously worked as: a. A construction worker under the National Coal Mine Construction Agreement of 1981, or b. A western surface miner under a western surface coal wage agreement, or c. A coal hauler under the Western Pennsylvania Coal Haulers Agreement of 1981, or d. An employee of a coal mining company that is not signatory to the National Bituminous Coal Wage Agreement of 1981. Will his/her copayments made during his/her prior employment count as credit towards his/her copayment maximum under the Plan? Answer: No. FILE: 81-61.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-61 Subject: Copayments for Individuals Covered Under One Agreement During One Copayment Year References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (8) Question: A pensioner worked for and is covered by a company, signatory to the 1981 Coal Wage Agreement. This company goes out of business and no successor company is indicated. The Funds assumes health and death benefits obligations of retired pensioners last employed by this company. Can the co-payments made by the pensioner under the company be counted towards his copayment maximum under the Funds' coverage? Answer: Yes. FILE: 81-62.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-62 Subject: Coordination of Benefits/Copayments References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (8) Question: The wife of a Beneficiary receives coverage for health benefits under her non-coal industry employer's benefit plan. She also is eligible for coverage as a dependent under the Funds. Can the coverage provided by her employer's plan be counted towards her Funds' copayment maximum for physician services and medications? Answer: No. FILE: 81-63.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-63 Subject: Copayments for HMO Enrollees References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (8) and A (10) (a) Question: Do the copayment provisions of the Plan apply to Beneficiaries enrolled in Health Maintenance Organizations? Answer: No. The scope of benefits under the Plan, including the copayment provisions, does not apply to a Beneficiary enrolled in an HMO. The Beneficiary makes a free election between the HMO benefit structure and that provided by the Plan. If the Beneficiary elects the HMO, he/she assumes responsibility for paying for any copayments imposed by the elected HMO, as well as for any charges in excess of the cost of health benefits provided under this Plan. FILE: 81-64.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-64 Subject: Copayment for Insulin and Insulin Supplies References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (4) (a), and A (8) (b) Question: Are the following subject to copayments? a. Insulin b. Insulin supplies (including syringes and needles) Answer: a. Yes b. No FILE: 81-65.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-65 Subject: Vision Care References: Amended 1950 and 1974 Benefit Plans and Trusts, Article III, Sections A (1), (2), (3), (4), (8), (9), and (11) (a) 22 Question: 1. What benefits are provided for eye care under the Plan, other than routine eye care provided in Section A (90), Vision Care Program? 2. Are benefits provided for a medication prescribed by a physician for the treatment of an eye disease or injury? Answer: 1. Benefits are provided for the following: o Eye examinations (but not refractions) and the full cost of corrective glasses or contact lenses when medically required because of a surgically caused refractive error. o Eye surgery and other treatment of eye illnesses and injuries o Eye specialists' care o Replacement lenses or eyeglasses for eye surgery patients, as provided in Article III, Section (11). 2. Yes, but only for those drugs which by Federal or State law require a prescription and are dispensed by a licensed pharmacist. These drugs are subject to copayment. Drugs used in connection with eye examinations are considered part of the cost of the examination. Drugs prescribed in connection with the Vision Care Program are specifically excluded from coverage under Section (9) (c) 3. FILE: 81-66.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-66 Subject: Orthoptics References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (3), A (6) (b), A (7) (b) and A (9) (c) 4 Question: Are benefits provided for orthoptics*? Answer: No. *Orthoptics: a technique of eye exercises designed to correct the visual axis of eyes not properly coordinated for binocular vision. FILE: 81-67.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-67 Subject: Vision Care When Lens Prescription Does Not Meet Benefit Requirements References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (9) (a) and (b) Question: Are benefits provided for vision examinations and frames if the lenses do not meet the prescription change requirements defined under the Vision Care Program? Answer: Yes, but only once every 24 months. FILE: 81-68.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-68 Subject: Ocularists' Services References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (7) (a) 1 Question: Are benefits provided for ocularists' services (the manufacturing of artificial eyes)? Answer: Yes, when prescribed by a physician and when medically necessary. FILE: 81-69.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-69 Subject: Vision Care Replacement of Broken Lenses References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (9) (b) (c) 6 Question: Are benefits provided for the replacement of broken lenses when the prescription has not changed, but the Beneficiary has not used the Vision Care Program benefit? Answer: No. Replacement of broken lenses is excluded from coverage, unless the replacement lenses have met both the frequency and prescription limitations specified under the Vision Care Benefit. FILE: 81-70.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-70 Subject: Services Determined by Medicare as Not Medically Necessary References: Amended 1950 and 1974 Benefit Plans and Trusts, Article III, Section A (10) (f) Question: Are benefits under the Plan provided to Medicare-enrolled Beneficiaries for hospitalization services denied by Medicare as not medically necessary? Answer: As a general rule, the Funds will not pay for services which Medicare has denied as not medically necessary. FILE: 81-71.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-71 Subject: Reimbursement for Non-Assigned Claims References: Amended 1950 and 1974 Benefit Plans and Trusts, Article III, Section A (1) (f) and (h) 6 Question: When a provider refuses to bill the Funds directly for covered services, will the Beneficiary be required to submit with his claim evidence of payment, or simply evidence of incurred expenses (e.g., a bill)? Answer: Evidence of incurred expense is sufficient. The Beneficiary should submit an itemized statement from the provider. If the Beneficiary receives payment from Medicare, she/he should indicate the amount of payment. FILE: 81-72.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-72 Subject: Benefits for Services and Facilities that are not Medicare Approved References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (5) (a) and A (10) (f) Question: 1. Are benefits under the Plan provided to Medicare-enrolled Beneficiaries for services that are not covered by Medicare? 2. Are benefits under the Plan provided to Medicare-enrolled Beneficiaries for services rendered in a facility, such as a nursing home, that is not licensed and approved by Medicare? Answer: 1. Yes, to the extent such services are provided under the Plan. 2. Yes. The Plan Administrator may authorize a Beneficiary's stay in a facility that is not Medicare-approved for these reasons: a. a Medicare-approved facility is not available (i.e., not present); b. a Medicare-approved facility cannot be used by the Beneficiary for reasons including, but not limited to, the following: 1) the facility is already operating at full capacity and cannot accept new patients 2) the Beneficiary does not live within the facility's service area Such a stay must have prior approval of the Plan Administrator and must also be medically necessary and meet the requirements established under the applicable provisions of the Plan. FILE: 81-73.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-73 Subject: Wigs References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (11) 9 and 27 Question: Are benefits provided for wigs necessary because of the following conditions: 1. alopecia (loss of hair)? 2. alopecia caused by disease or chemotherapy treatment? Answer: 1. and 2. No. Benefits are not provided for cosmetic items or personal comfort items not necessary to the treatment of an illness or injury. FILE: 81-74.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-74 Subject: Pulmonary Function Testing References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (2) (c), A (3) (j), A (6) (e) and A (11) 6 Question: Is pulmonary function testing a covered benefit? Answer: Yes, but only if such testing is ordered by a physician and is for the purpose of diagnosing a pulmonary condition. In such cases, the physician and laboratory charges are covered and copayment is applicable for each physician's visit. Charges for a pulmonary function test for the specific purpose of supplying evidence for a black lung application, as required by State or Federal Black Lung legislation, are not covered. FILE: 81-75.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-75 Subject: Inpatient Diagnostic Evaluations References: Amended 1950 and 1974 Benefit Plans and Trusts, Article III, Sections A (1) (a) and A (11) (a) 16 Question: If a Beneficiary is confined as an inpatient in an accredited hospital solely for a diagnostic evaluation that could be provided on an outpatient basis, are benefits provided for the: a. diagnostic evaluation? b. inpatient stay? Answer: a. Yes. b. No, because the inpatient stay is not medically necessary. FILE: 81-76.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-76 Subject: Stationary Bicycle Ergometer References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Sections A (11) (a) 23 and A (6) (d) Question: Are benefits provided for home use of a stationary bicycle ergometer* as part of a cardiac rehabilitation program? Answer: No. *Ergometer:an instrument used for measuring the amount of work done by a muscle over a period of time. FILE: 81-78.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-78 Subject: Hearing Aids References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (7) (d) and (8) Question: 1. Will hearing aids be considered physician's charges or prescription drugs? Some states require prescriptions before dealers can sell them. 2. How will the deductible be applied? Answer: 1. Neither. They are categorized as "Other Benefits" (medical supplies). 2. Hearing aids are not subject to copayment. FILE: 81-79.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-79 Subject: Charges for Semi-private Room Benefit References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (1) (a) and Section A (11) (a) 12 Question: What is the semi-private room benefit for: 1) a beneficiary who dies shortly after being admitted, and 2) a beneficiary who is transferred to another facility shortly after being admitted? Answer: Whatever is charged, but not to exceed the most common semi-private one-day room rate. FILE: 81-80.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-80 Subject: Marital Counseling References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (7) (f) Question: Are benefits provided for marital "counseling"? Answer: Benefits are not provided for marital counseling unless ordered by the attending physician as part of treatment for mental illness, alcoholism, or drug addiction. FILE: 81-81.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-81 Subject: Definition of "Copayment Year" in Determining Copayment Maximum References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (8) (a) a and b Question: If beneficiaries become eligible for Funds' benefits anytime after the beginning of a copayment period, as set forth in Article III. A. (8), will they be required to meet the same copayment maximum as beneficiaries eligible as of the beginning of that 12-month copayment period? Answer: Yes. For example, if a non-working beneficiary becomes eligible on March 1, he/she would be required to pay up to the $50 prescription drug and the $100 medical care copayment maximum in the 12-month copayment period, even though he/she might actually have been an eligible beneficiary during 1/12 of that 12-month period. FILE: 81-82.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-82 Subject: Inpatient Hospital and Physician Coverage Associated with the Provisions of Non-Covered Benefits References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (1) (g) Question: A beneficiary acquires a condition, the treatment for which is not a covered benefit (e.g., dental treatment or oral surgery). Hospitalization is required for this treatment only because of a pre-existing condition (such as heart disease), the treatment for which is a covered benefit. 1. Are benefits provided for the hospitalization costs? 2. Are benefits provided for the physician's fees associated with care for the prior condition? 3. In the case of the non-covered service, i.e., dental treatment, are benefits provided for the charges associated with it? Answer: 1. Yes, if prior approval is obtained from the Plan Administrator. 2. Yes. Benefits are provided for charges associated only with the prior condition, which is a covered benefit. 3. No. (Dental services are not a covered benefit.) FILE: 81-83.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-83 Subject: Laboratory Tests and x-Rays References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (2) (c) and Section A (3) (j) Question: Under the 1981 Agreement benefits are provided for laboratory tests and X-rays. When performed in the outpatient department of a hospital, they must be ordered by a physician for "diagnosis or treatment of a definite condition, illness or injury" (Article III, Section A (2) (c). When performed in a licensed laboratory, they must be ordered by a physician for "diagnosis and treatment of a definite condition, illness or injury" (Article III, Section A (3) (j). Is there a difference in these two benefits? Answer: No. Laboratory tests and X-rays, whether performed in the outpatient department of a hospital or in a licensed laboratory, must be ordered for diagnosis or treatment of a definite condition, illness or injury; that is; there must be specific symptoms requiring laboratory tests or X-rays for further diagnosis or treatment. As an example, benefits are provided for laboratory tests related to the determination of pregnancy. Benefits are not provided for laboratory tests or X-rays ordered in connection with a routine physical examination, unless the examination is considered medically necessary by a physician. FILE: 81-85.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-85 Subject: Follow-up Care to Emergency Treatment References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (2) (a) and (3) (i) Question: 1. A beneficiary requires follow-up services to emergency treatment which are rendered beyond the 48-hour initial emergency care limitation, and which are also rendered in an emergency room. Are benefits provided for both the medical treatment and the emergency room charges? 2. A beneficiary requires emergency room treatment and receives it within 48 hours of the onset of acute symptoms. After the 48-hour period has expired the acute symptoms reappear. If the beneficiary goes to the emergency room for treatment within 48 hours of the reappearance of the acute symptoms, are benefits provided for both the medical treatment and the emergency room charges? Answer: 1. In this situation, the charge for emergency room service is not covered. However, benefits will be provided for charges for medical treatment which is otherwise covered under the Plan. 2. Yes FILE: 81-87.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-87 Subject: Nonduplication of Benefits References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (10) (h Question: The nonduplication of benefits provisions in the 1950 and 1974 Benefit Plans and Trusts state that benefits will be reduced, in certain circumstances, by benefits provided by another group plan. a. Which of the following are considered group plans? 1. An individual medical coverage policy bought by a miner or a member of the miner's family; 2. a school accident policy, paid for entirely by the parents, which only covers accidents; 3. a health care plan provided through employment, coverage paid for by the employer, employee, or both; 4. health coverage provided through a plan which is only available to members of a particular organization or group, i.e., Elks, AAA, YMCA. b. If another plan is not a group plan, what effect does coverage under that plan have on payment by the Funds? Answer: a. Numbers 3 and 4 are "group plans". b. Coverage under that Plan has no effect on payment made by the Funds. FILE: 81-88.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-88 Revised: April 7, 1988 Subject: Oral Orthopedics References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (3) (e) and (m), and A (11) (a) 19 Question: Are benefits provided for treatment of Temporomandibular Joint Dysfunction? Answer: No, except when treatment involves: 1. the use of corrective external orthopedic appliances; or 2. corrective surgery to specifically reorient the temporomandibular joint. Benefits are not provided for treatment for T.M.J. which involves the insertion of dentures. FILE: 81-89.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-89 Subject: Specialists Care/Dentistry References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (3) (e), (m), and (11) (a) 19 Question: Are benefits provided for the biopsy of a lesion on the roof of the mouth if performed by a dentist? Answer: Yes, if prior approval has been obtained from the Plan Administrator. FILE: 81-90.DOC **Additional Properties available via IPropertyStorage. ---------------------------------------------------------------------- Attribute = B725F130-47EF-101A-A5F102608C9EEBAC\19 idChunk = 1 BreakType = 1 (Word) Flags(chunkstate) = 0x1 (Text) Locale = 1033 (0x409) IdChunkSource = 1 cwcStartSource = 0 cwcLenSource = 0 ---------------------------------------------------------------------- Control Number: 81-90 Subject: Oxygen References: Amended 1950 & 1974 Benefit Plans & Trusts, Article III, Section A (8) and Section A (6) (e) Question: Is oxygen considered a drug? If so, is it subject to copayment? Answer: Because a prescription is required to obtain it, oxygen has historically been processed as part of the drug program. However, it is not a drug. The length of supply is usually unknown, the charges are for both oxygen and equipment, and the supplier is usually not a pharmacy. Also, oxygen is not listed under the prescription drug benefit in the contract, nor under the copayment section. Therefore, it is not treated as a "prescription drug" and is not subject to copayment.