LINECo

Covered Medical Expenses

Some features of the Plan described on this page have been affected by the December 2010 Summary of Material Modifications (SMM), effective January 1, 2011. Click here to access the SMM.

Note: For information about the extended acupuncture benefit, please click here.

Covered medical expenses are the actual reasonable and customary charges incurred for the following types of services and supplies which are medically necessary and, except where specifically stated otherwise, required in connection with the treatment of a person's injury or sickness and which are acceptable to be considered for payment under the Comprehensive Benefit. The amount payable is subject to the maximum benefits and limitations shown on the Schedule of Benefits and to all other limitations and exclusions that apply. Only the amount of a charge that is reasonable and customary is considered a covered medical expense.

Hospital Services and Supplies
- Daily room and board, if semi-private or ward accommodations are used, and general duty nursing care, excluding professional services of doctors, private duty nurses or any individual nursing care, regardless of what it is called. If a private room is used, only the hospital's most common charge for a semi-private room is a covered medical expense.
- Other hospital services and supplies furnished to a person which are medically necessary and required for treatment of the person, excluding room and board, professional services of doctors and private duty nursing.
Outpatient Hospital and Ambulatory Surgical Center Services and Supplies furnished as a result of outpatient surgery and treatment of accidental injury.
Important - If a dentist recommends that a person have a dental procedure performed in a hospital (on an inpatient basis or in the hospital outpatient department) or in an ambulatory surgical center, a doctor who is an M.D. or D.O. must certify the medical necessity of having the procedure performed in such a setting. The doctor must submit a letter to the Fund Office prior to the treatment, giving the medical reasons the procedure should be performed in a hospital or ambulatory surgical center instead of the dentist's office. Be sure to contact the Fund Office for advance approval of any such treatment. (If only the dentist certifies the medical necessity, or if the doctor's letter is not received before the treatment is performed, or if the Fund Office does not approve the treatment, the hospital or ambulatory surgical center expenses will not be paid.)
Doctors' professional services, rendered either in or out of a hospital for surgery and medical care and treatment.
Services of other covered providers, such as services rendered by a physician's assistant, a certified registered nurse anesthetist (CRNA), a licensed nurse practitioner (LNP), or a surgical assistant, if such services are rendered within the scope of the provider's license.
With respect to charges by a physician (M.D., D.O., or D.P.M.) who is providing surgical assistance, the maximum allowable covered medical expense is 25% of the reasonable and customary surgeon's fee.
Physical Therapy rendered by a registered physical therapist on an inpatient or outpatient basis, provided the therapy is recommended by the attending doctor.

Outpatient Speech Therapy rendered by a qualified speech therapist, limited to therapy for a person who had normal speech and lost it as a result of sickness or accidental injury or as required for a child after repair of a cleft palate. Speech therapy for a child for any other diagnosis is not covered. (See the Schedule of Benefits for limitations on outpatient speech therapy.)

Well-child care, as follows:
1. Immunizations and the doctor's professional fees for the related office visit, payable up to a lifetime maximum benefit of $1,000 per child. No deductible applies to immunizations.
2. ONLY for a child whose mother called MCM and completed the Prenatal Care Program (page 51) - Up to $500 for the following services provided from birth through age 4 years: routine in-hospital care after birth, routine check-ups and immunizations. The mother must be a covered employee or dependent spouse, and the child must be covered under the Plan at the time the care is received.
Note: If a child qualifies for the $500 Prenatal Care Program benefit, those benefits will be paid first. Charges for additional immunizations will then be considered under the $1,000 immunization benefit.

Transportation services only as follows:
- Emergency local transportation by professional ambulance service other than air ambulance, limited to the first trip to and from a hospital for any one sickness and for all injuries sustained in any one accident; and
- If the attending doctor certifies that a person's disability requires specialized or unique treatment that isn't available in a local hospital, transportation to get the treatment is covered, subject to the following limitations: (a) the transportation must be by regularly scheduled commercial airline or railroad or by professional air ambulance; (b) the transportation may only be from the town where the injury or sickness occurred to the nearest hospital qualified to provide the special treatment (which may or may not be the hospital where the individual wants to be treated); (c) only the first trip to and from the hospital for any one sickness and for all injuries resulting from any one accident are covered; and (d) the transportation is limited to the United States or Canada.
  Note: If you have no control over which ambulance service is used, the Plan will pay the related covered charges at 80%, even if the ambulance service is not in the PPO network.
Dental treatment, limited to treatment of accidental injury to sound natural teeth, including the initial replacement of such teeth and any necessary dental x-rays, provided the first treatment is received within 6 months of the accident causing the injury.
X-RAY, LABORATORY examinations, and diagnostic imaging and tracing services (such as EKGs, MRIs, computerized scans, sonograms, mammograms, etc.) that are ordered by a doctor, including services of radiologists and pathologists.
For employees, retirees and their spouses:
- Covered medical expenses also include such procedures when provided for purposes of routine (preventive) health screening, provided the tests are appropriate for the patient's age, sex and medical history and are consistent with prevailing medical standards.
- Benefits for diagnostic x-rays, lab work, and imaging and tracing services performed in a calendar year will first be provided under the Diagnostic X-Ray and Lab (DXL) Benefit. If the covered medical expenses for such services in a calendar year exceeds the DXL Benefit maximum benefit, the excess will be considered under the regular provisions of the Comprehensive Benefit.
Genetic testing - The Plan covers genetic testing only if the tests are performed in connection with an actual treatment plan for a diagnosed illness.
Radiological services and supplies for x-ray treatments, radon, radium and radioactive isotopes.
Anesthetics and their administration.
Maternity expenses for delivery in a hospital, and medically necessary services and supplies provided in connection with delivery in a birthing center or at home, including the services of a licensed midwife used instead of a doctor, and circumcision of a newborn male child during the first 30 days after birth. (Other care of a well newborn child is not covered except as stated in No. 7.)
Note About Length of Maternity Confinements - An eligible female employee, retiree or dependent spouse, and her newborn infant, are entitled to at least 48 hours of inpatient hospital care following a normal delivery and at least 96 hours of inpatient hospital care following a Caesarean section. (The attending provider may however, after consulting with the mother, discharge the mother and newborn earlier than 48 hours following a vaginal delivery or 96 hours following a Cesarean section.) The Plan will provide benefits for the covered medical expenses incurred by an eligible female employee or dependent spouse during the prescribed time periods, subject to the applicable deductibles, payment percentages payable and maximum benefits shown on the Schedule of Benefits.
Hospice Care, subject to Provisions Governing Hospice Care starting on page 52.

Home Nursing Care: part-time or intermittent nursing care provided by home health aides under the supervision of an R.N. (services of an R.N. or L.P.N. are covered if the patient's condition requires the professional services of a trained nurse) and medical supplies (other than drugs and biologicals) provided by the home health agency, up to a maximum benefit of $5,000 per year, subject to the following requirements:
1. The services and supplies must be provided by or through a home health agency as defined on page 80;
2. A program of home nursing care must be established and approved in writing by the patient's doctor within 7 days after termination of an inpatient hospital stay; and
3. The doctor must certify that the home nursing care is for the same or related condition for which the patient was hospitalized and that proper and medically necessary treatment of the patient's condition would require hospital confinement in the absence of the services and supplies provided as part of the program of home nursing care.
Exclusion - No payment will be made for child care or housekeeping services.

Contact the Fund Office before arranging for any home nursing care for anyone in your family.

Skilled nursing facility care, including room and board and medically necessary services and supplies provided to a person in a skilled nursing facility for up to 30 days per year, subject to the following requirements:
1. A doctor must certify that the confinement and nursing care are necessary for the patient's recuperation from an injury or sickness;
2. The confinement must be preceded by at least 3 consecutive days of a hospital stay for which Plan benefits are payable;
3. The confinement must start within 3 days after termination of a hospital stay for which Plan benefits are payable or within 3 days after termination of a skilled nursing facility stay for which Plan benefits are payable;
4. The skilled nursing facility stay must be due to the condition which required the previous hospital stay; and
5. The confinement must be provided in a facility which meets the following Plan's definition of a skilled nursing facility (page 81).

Non-Surgical Treatment of TMJ, including hospital and doctors' services, and other medically necessary services and supplies provided for or in connection with non-surgical treatment of TMJ, up to a $1,000 lifetime maximum benefit payable per person. (The Plan's definition of TMJ is on page 81.)
Note - No benefits of any kind are provided under the Dental Benefit for non-surgical treatment of TMJ.

Jaw Surgery (includes TMJ surgery), including hospital and doctors'/surgeons' services, and other medically necessary services and supplies provided for or in connection with the surgery. Jaw surgery must be precertified by Medical Cost Management (MCM). If the surgery would otherwise have been covered but is not precertified by MCM, or is not performed by a BCBS PPO provider at a BCBS PPO facility, the maximum benefit payable for all covered expenses will be $3,000 per person.
Note - No benefits of any kind are provided under the Dental Benefit for TMJ/jaw surgery.
Medical Supplies, such as:
1. Drugs and medicines which may only be legally dispensed by a registered licensed pharmacist according to a doctor's written prescription which includes the name of the drug, and certain diabetic supplies not requiring a doctor's prescription. (Medications and supplies that can be dispensed without a written doctor's prescription are not covered, even when there is a written doctor's prescription.) Prescriptions may only be filled for up to a 90-day supply at one time. (Refer to Prescription Drug Programs starting on page 54 for more information about obtaining prescription drugs.)
2. Whole blood (if not donated or replaced) or blood plasma and the administration of such substances.
3. Bandages, surgical dressings, casts, splints, trusses, crutches and orthopedic braces.
4. Surgical supplies, including the first charge incurred for surgical supplies required to aid any impaired physical organ or part in its natural body function.
5. Appliances, and prostheses (such as artificial limbs and eyes) to replace physical organs or parts of organs. Lineco will cover the initial prosthesis or appliance and up to two replacement prostheses or appliances during the individual's lifetime. Replacement prostheses will be covered only if the need for the replacement is certified as medically necessary by Medical Cost Management (MCM). Covered medical expenses also include breast prostheses following a mastectomy.
6. Oxygen and rental of the equipment for the administration of oxygen.
7. Rental of a wheelchair, a hospital-type bed, an iron lung or other similar therapeutic equipment that is medically necessary for treatment.
8. The first pair of contacts following cataract surgery, or up to $200 for the first pair of eyeglasses following cataract surgery.
9. Enteral or parenteral nutrition, including its administration, provided that such services and supplies are: (1) administered in accordance with a treatment plan that has been approved and is being managed by MCM; (2) prescribed by a physician; (3) medically necessary to replace oral feeding in a patient who is unable to take oral nutrition as the result of sickness or accidental bodily injury; and (4) is the primary source of the patient's nutrition.
10. Custom-made orthopedic shoes for diabetics - Orthopedic or therapeutic shoes that are prescribed by a physician for treatment of a diabetic foot disease. The shoes must be custom-fitted by a podiatrist or other qualified individual. Covered expenses will be limited to the following each calendar year: (a) one pair of custom-molded shoes, including the inserts provided with the shoes, and up to two additional pairs of inserts; or (b) one pair of extra-depth shoes, not including the inserts provided with the shoes, and up to three additional pairs of inserts. In either case, a modification of the shoes may be covered instead of an allowable pair of inserts (other than the initial set).
Colorectal cancer screening procedures, subject to Provisions Governing Colorectal Cancer Screenings starting on page 50.

Bariatric (obesity) surgery for an eligible employee, retiree or spouse, but only if ALL the following requirements are met:
1. The patient must be at least 100 pounds over his medically desirable weight and have a Body Mass Index (BMI) of at least 40;
2. The obesity must be threat to the patient's life due to the existence of complicating health factors such as diabetes, heart trouble, hypertension, etc.;
3. During the 12-month period prior to the proposed surgery, the patient must have a documented history of at least 6 continuous months of physician-assisted attempts to reduce weight by more conservative measures (there must be at least 7 office visits: the initial visit plus one monthly visit for 6 months);
4. The surgery must be performed in a BlueCross PPO facility; and
5. Before surgery is performed, Lineco must be contacted for a review of the medical history and treatment plan, and Lineco must authorize the treatment as medically necessary.
Obesity surgery will be covered only once in a patient's lifetime. No benefits are payable for obesity surgery performed on dependent children.

Hearing exams, tests and hearing aid devices, paid at 80% (no deductible) up to a maximum benefit of $1,250 per ear every five years (60 months) for adults, and every two years (24 months) for children.
Note - You can receive significant discounts on hearing services, including hearing aids, through the HearPO network. You can also get steep discounts on hearing aid batteries mailed directly to your home. Refer to your HearPO brochure or call 1-(888)-HEARING (432-7464) for more information. You are not required to use a HearPO provider to receive hearing benefits.
Erectile dysfunction drugs following a radical nerve-sparing prostatectomy. Coverage is limited to 10 tablets per month for the 12-month period immediately following the prostatectomy.

Adult immunizations (for employees, retirees, and spouses). Coverage is provided for immunizations on the list of recommended adult immunizations prepared by the U.S. Centers for Diseases Control (CDC). The following is the list of CDC-recommended immunizations at the time this booklet was printed:

Immunization	Age 19-26	Age 50-59	Age 65+
Hepatitis A	2 doses if high risk
Hepatitis B	3 doses if high risk
HPV (human papillomavirus)	3 doses (females)
Influenza	annually if high risk	annually
MMR (measles, mumps, rubella)	1 or 2 doses	1 dose if high risk
Meningococcal	1 or more doses if high risk
Pneumonia	1 or 2 doses if high risk		1 dose
Td/Dtap (tetanus, diptheria, pertussis)	one dose + booster every 10 years		every 10 years
Varicella	2 doses
Zoster			1 dose

You are not required to prove that you are in a high risk category. That determination is between you and your physician.

(If the list changes, the list in effect at the time the service was rendered will determine whether a specific immunization is covered.)

For a list of the types of charges that are not covered under the Comprehensive Benefit or any other Plan benefit, refer to What the Plan Does Not Cover starting on page 72.

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Covered Medical Expenses

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