Should I pre-certify any services for Funds beneficiaries?
Yes. You should pre-certify inpatient hospital stays, skilled nursing stays, rehabilitative therapy, mental health services, home health services, durable medical equipment, oxygen equipment and hearing aids.
If you are planning elective surgery, the following should be pre-certified: organ transplants, intestinal or gastric bypass for obesity, cerebellar and dorsal stimulator implants, insertion of a prosthesis for cleft palate, plastic surgery including mammoplasty, and reduction mammoplasty.
Please call 1-800-292-2288 to pre-certify services
Can I refer a Funds beneficiary to any health care provider for additional care?
The Funds has a Network of Cooperating Funds Providers that should be used for all medical services. These providers have a relationship with the Funds and will not balance bill the beneficiary for services after the Funds payment (except for applicable co-payments). You can learn who the Cooperating Funds Providers are in your area by contacting your Funds Provider Representative.
Except for Durable Medical Equipment (DME) and Hearing Aids, a Funds beneficiary may go to providers outside the Funds Cooperating Provider Network. However, the beneficiary may be billed for amounts in addition to the Funds payment and the beneficiary’s copayment.
The Funds' network for Durable Medical Equipment (DME) and Hearing Aids must be used for obtaining those services. Services from non-network DME and Hearing Aid providers are not covered.
Is the Funds the Medicare payer for all medical expenses?
No, the Funds is the Medicare Part B payer for non-facility providers. Hospitals, skilled nursing facilities, home health care, and other facilities must first bill Medicare Part A for services and may then bill the Funds plan as the secondary payer.
Does the Funds cover Home Health Care services?
Yes, with a doctor’s order, skilled nursing care, physical therapy, and speech therapy may be provided by licensed personnel from a certified home health agency. For Medicare covered beneficiaries, Medicare is the primary payer and Medicare Part A must approve these services. Home health visits for activities of daily living (bathing, feeding, and house cleaning, etc.) are not covered.
Will the Funds cover services from a Skilled Nursing Care Facility?
Subject to prior approval, coverage is provided for medically necessary skilled nursing care in a skilled nursing care facility. For Medicare covered beneficiaries, Medicare Part A covers the first 100 days of skilled care. The Funds can cover services in excess of 100 days if the Funds pre-certifies the services as skilled care. To pre-certify, please call the Precertification Department at 1-800-292-2288. Nursing home stays for custodial care (personal care, feeding, toileting, etc.) are not covered.
Does the Funds cover Hearing Aids?
Yes, however, the hearing aids must be ordered through one of the Funds’ Network Hearing Aid vendors and must be approved by the Funds’ Prior Authorization Department (800-292-2288). A hearing aid purchased from a vendor not in the Funds’ network is not covered.
Does the Funds cover Routine Vision Care?
Yes, the Funds covers routine eye exams, eyeglasses, and contact lenses once every 24 months. Payment for eye glasses and contact lenses is a fixed and limited amount and the beneficiary is responsible for any additional payment over the fixed and limited amount.
Does the Funds cover Non-emergency Transportation?
Yes, if the beneficiary needs to schedule a medical appointment but does not have transportation to get to the appointment the beneficary may be eligible for non-emergency transportation benefits. The beneficiary should call 1-800-292-2288 to inquire about this benefit.
Is Preventive Care covered?
Coverage is provided for immunizations, screenings for high blood pressure, diabetes, and other conditions, and for medically necessary tests to detect cancer, blindness, and deafness.
** Note – the 1993 and the Prefunded Benefit Plans do not cover preventive office visits for non-Medicare beneficiaries between the ages of 6 and 55. **
Is Chiropractic Care covered?
Although the Funds does not cover these services, Medicare does cover some chiropractic services. If the beneficiary is eligible for Medicare, the Funds will pay for chiropractic services covered by Medicare Part B. The beneficiary is responsible for any copayments or coinsurance amounts due after the Medicare Part B payment is made.