Benefit Summary: Medical Benefits


Overview

Your Comprehensive Major Medical Benefit is designed to substantially cover most forms of medically necessary care. This coverage is subject to various deductibles, copayments, coinsurance, and other limits.


Blue Card PPO

The Blue Card PPO Network is a network of hospitals and physicians throughout the United States that participate in their local BlueCross BlueShield PPO networks. Blue Card PPO providers are Lineco's preferred providers and provide medical care to Lineco participants at negotiated rates.

When you use Blue Card PPO hospitals and doctors for your medical care, you save money twice. First, because the rates charged by PPO providers are usually lower, and second, because the Plan will pay a higher percentage of your covered expenses.   You are not required to use a preferred provider--the choice of a hospital and a doctor is solely yours to make.

To find Blue Card PPO Providers:
  • Go to www.bcbsil.com on the internet and follow the links
  • Call 1-(800)-810-BLUE (2583).


Deductibles

Before any payments are made by the plan you must satisfy the annual deductible. (Note that certain specified benefits are not subject to the deductible.) Only covered expenses apply to the deductible.

Individual Deductible
$300 per calendar year

Family Deductible
$600 per calendar year.

Hospital certification noncompliance
$250 per admission (does not go towards calendar year deductible).

Emergency room
$100 for each occurrence of hospital emergency room treatment (deductible is waived if the patient is admitted as an inpatient).



Payment Percentages

The percentage of the charges that the plan pays for most covered expenses after the deductible(s) have been satisfied. You pay the remaining percentage of the charges (that portion is called your percentage copay). For more specific information, see the .

Covered services provided by PPO providers and covered prescription drugs not purchased through the Prescription Drug Mail Service Program:

Before out-of-pocket maximum is met - 80%
After out-of-pocket maximum is met - 100%

Chiropractic care - 50% up to a calendar year maximum benefit of $600

Covered services provided by non-PPO providers:

Before out-of-pocket maximum is met - 70%
After out-of-pocket maximum for all other covered medical expenses is met - 100%

Chiropractic care - 50% up to a calendar year maximum benefit of $600



Out-of-Pocket Maximums

Once your percentage copays during a calendar year reach the out-of-pocket maximum, the Plan will pay a higher percentage of any further covered expenses during that year.

Per person, unless the person is eligible for Medicare - $2,000
Per person, if the person is eligible for Medicare - $1,625
Per family - $4,000

Note that the following does NOT count towards the out-of-pocket maximum: hearing care.



Maximum Benefit

Calendar Year Maximum Benefit Payable - unlimited per person covered



Preventive Care Benefit

Benefits for covered preventive services are paid at 100% when you use a Blue Cross Blue Shield (BCBS) PPO provider and at 70% if you use an out-of-network (non-PPO) provider. No deductible will apply to PPO expenses, but the calendar year deductible will apply to non-PPO expenses. (To find a BCBS PPO provider, go to http://www.bcbsil.com, or call 1-800-810-BLUE [2583].)

Routine physical exams will be covered under the Preventive Care Benefit at a frequency of one per year.

Screening for colorectal cancer (adults age 50-75) will be covered under the Preventive Care Benefit within the age and frequency guidelines established by the American Cancer Society (which recommends that persons at average risk should have an initial colonoscopy at age 50), including colorectal exams, flexible sigmoidoscopies, barium enemas, and colonoscopies.

Most adult immunizations (for employees, retirees, and spouses) will be covered under the Preventative Care Benefit.

Childhood Immunizations will also be covered under the Preventative Care Benefit. Children 0-18 will receive 100% coverage for both in- and out-of-network providers. Older children (19-25) will receive 100% coverage for in-network and 70% after the deductible is met for out-of-network.

Lab and x-ray charges related to covered preventive care will be covered under the new benefit. Other such charges are covered under the DXL benefit (see below).



Diagnostics, X-Ray, Lab (DXL)

100% up to $150 per calendar year (no deductible)

If you have more than $150 in covered diagnostic x-ray and lab services in a calendar year, the remainder will be considered under the provisions of the Comprehensive Benefit.

The DXL benefit covers Employees, Retirees, and Spouses only. Preventive/routine lab and x-ray charges will no longer be covered under the DXL Benefit, but under the Preventive Care Benefit instead.


Most Common Medical Services

Click here for specific information about the many common medical services that the Plan covers under the Comprehensive Medical Benefit.


Special Limitations

Unless stated otherwise, the Plan payment percentages for the following types of treatment are as shown under Plan Payment Percentages above. However, expenses for hearing care will NOT be paid at 100% even if your out-of-pocket maximum has been met.

Outpatient Speech Therapy:
      Maximum covered per session - $90
      Maximum number of sessions per person per year - 50

Non-Surgical TMJ Treatment: Lifetime maximum benefit per person - $1,000

TMJ/Jaw Surgery: Lifetime maximum benefit per person for jaw surgery that is: (a) out-of-network, or (b) in-network but not precertified - $3,000

Chiropractic Care:
      Plan payment percentage - 50%
      Calendar year maximum benefit per person - $600

Home Nursing Care: Calendar year maximum benefit per person - $5,000

Hearing Care: Maximum benefit payable per ear for hearing exams, tests and hearing aid devices, every 5 years (60 months) for adults and every two years (24 months) for children - 80% up to $1,250 (no deductible)

Skilled Nursing Facility Care: Maximum number of days payable per person per calendar year - 30

Hospice Care: Lifetime maximum benefit per person - $20,000