Medical

Welcome to your Medical Benefits. Click on any of the boxes below to read about what is covered under your plan and find any documents related to it.

The Plan covers Bariatric Surgery only when the required criteria are met. All covered expenses must be incurred at an in-network Center of Excellence. THERE IS NO COVERAGE FOR BARIATRIC SURGERY PERFORMED OUT-OF-THE PPO NETWORK.  Prior authorization is required for all bariatric surgery services. 

Please click here for a more detailed explanation of the benefit.

The Plan covers Chiropractic Care and Acupuncture OR Physical and Occupational Therapy only when the required criteria is met. Please click the specific link for more information.

The Plan covers chiropractic care and acupuncture only when all of the following criteria is met:

  1. Only when rendered by a physician; and,
  2. only for eligible participants, spouses, and dependents over the age of 5; and,
  3. only for the treatment of the back, neck, spine, and vertebra; and,
  4. only for conditions due to subluxation, strains, sprains, and nerve root problems.

The Plan does not cover physical therapy services provided by a Chiropractor. (See Physical Therapy benefits.) The Plan does not cover chiropractic care received at the same time as physical therapy.

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), allows you to extend certain coverage for yourself and your eligible dependents when certain circumstances, or qualifying events, would normally cause coverage to end.  Please click on the link(s) for more information.

COBRA Explained

COBRA Explained (Spanish)

Participant and Spouse
The Plan provides benefits for charges for immunizations rendered to an eligible participant or an eligible spouse.  Payment is 100% of the allowable charges.  The individual annual deductible does not need to be satisfied before receiving benefits.  The    Plan provides benefits for charges for Hepatitis B inoculations rendered to an eligible participant.  Payment is 100% of the allowable charge. The individual annual deductible does not need to be satisfied before receiving benefits.
Dependent Children
The Plan provides benefits for charges for vaccinations, immunizations, and laboratory tests that are required by the school for children in the school system and mandated by the Board of Education for eligible dependent children.  Payment is 100% of the allowable charges.  The individual annual deductible does not need to be satisfied before receiving benefits.

Employee Resources Systems provides all eligible participants and their families free access to the Member Assistance Program and Online Work-Life Services for information and resources. Counselors are available 24/7/365 to provide support and referrals.

  • For confidential help call any time 1-800-292-2780
  • Log on to www.ers-eap.com (UN:  laborers   PW:  foxvalley)

You deserve to benefit from the convenience of having MAP Counselors and Work-Life Consultants provide support services, research assistance, resources and referrals for matters related to these and other topics:

  • Marital and family conflict
  • Stress management
  • Budgeting & financial issues
  • Parenting challenges
  • Job performance
  • Childcare resources
  • Eldercare resources
  • Skill Builder online courses
  • Pet care
  • Daily living needs
  • Dining and entertainment
  • Prescription savings

The Plan provides benefits for mental disorder treatment. Allowable charges incurred for mental disorder treatment will be paid at 90% (80% if outside of the PPO Network) after the annual deductible for each eligible participant or eligible dependent each calendar year. Allowable mental disorder treatment charges count towards satisfaction of the Out‐of‐Pocket limit and are then paid in accordance with that provision. Charges for mental disorder treatment are covered when provided by a licensed psychiatrist or Doctor of Medicine. Treatment may be covered when provided by a clinical psychologist, licensed clinical professional counselor, or a licensed social worker if the treatment is prescribed by and under the ongoing supervision of a licensed psychiatrist or Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.).

A mental disorder treatment is any illness:

  • identified in the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). For the purpose of this benefit, it excludes psychological and/or physiological dependence or addiction to alcohol or psychoactive drugs or medications, regardless of any underlying physical or organic cause (treatment for these may be covered under the substance abuse benefit); and,
  • where the psychotherapy or other psychotherapeutic methods are the primary sources of treatment.

All inpatient services given by a mental health facility or area of a hospital that provides mental health or substance abuse treatment for an illness identified in the DSM are covered by the Plan. Detoxification services, adjustment reactions, developmental delays, and marriage and family counseling are not considered under this Plan to be mental disorder treatment.

Participant and Spouse
The Plan provides benefits for an annual routine physical exam performed by a Medical Doctor (M.D. or D.O.) for an eligible participant and eligible spouse.  Benefits include expenses incurred for X-ray and laboratory tests.  Payment is 100% of the allowable charges.  The individual annual deductible does not need to be satisfied before receiving benefits.  The Plan does not cover charges for services or supplies that are covered in whole or in part under any other provision of the Plan, any expense for a physical exam that is not performed by a physician, charges that exceed allowable charges, any expense incurred in connection with an illness or injury.
Dependent Children
The Plan provides benefits for a school physical for athletic participation and school physicalrequired by the school for children in the school system and mandated by the Board of Education for eligible dependent children.  Payment is 100% of the allowable charges.  The individual annual deductible does not need to be satisfied.  Routine physicals for dependent children are not covered.

The Plan covers Physical and Occupational Therapy services only when all of the following criteria is met:

  1. The services are provided by a registered physical therapist, or a registered or state licensed occupational therapist, for short-term therapy; and,
  2. the treatment is for the physical restoration of a physical disability for which there is a reasonable expectation of significant improvement in that disability as determined by the Plan; and,
  3. the services are ordered by the treating physician under an individual treatment plan and must be certified by the treating physician as necessary for the improvement of the patient’s condition through short-term care which is limited to a maximum of 26 weeks; and,
  4. the treating physician provides a written prescription which includes frequency, duration, and prognosis.

 

Short-term care is defined as the “up to 26 weeks” period beginning on the first day of physical therapy. The “up to 26 weeks” period is considered continuous if there is no gap in the course of treatment from the first day of therapy. A gap of larger than one month in duration is considered to be a break in treatment and ends the coverage of physical therapy for that specific condition.

In the event of an accidental injury resulting in hospitalization, a participant may request an extension of short term therapy benefits. Requests for an extension of the maximum 26 week period must be recommended by a physician and reviewed by Case Management. An extension of benefits will be considered only after a medical review to determine medical necessity, reasonable expectation of significant improvement, and non-experimental treatment status according to accepted standards of medical practices through established medical review mechanism. Extension of benefits will be approved in four week increments with an overall maximum benefit of no more than 52 weeks.

In addition, occupational and physical therapy services will be covered for treatment of a dependent with a congenital disability without regard to the reasonable expectation of significant improvement of the disability or the short-term care of up to 26 weeks limitation.

The Plan covers Organ Transplants only when the required criteria is met. All covered expenses must be incurred at an in-network transplant Center of Excellence for all covered transplants except cornea and kidney incurred at a PPO hospital. THERE IS NO COVERAGE FOR TRANSPLANTS PERFORMED OUT-OF-THE PPO NETWORK. Prior authorization is required for all covered transplant services. 

Please click here for more information.

The Welfare Plan can help replace part of your income if you become temporarily disabled and cannot work.  To receive this benefit you must be eligible, totally disabled, unable to perform your job and under the care of a medical doctor. Refer to the attachment for a detailed explanation of the Weekly Loss of Time benefit.

Please click here for more information.