Michigan Conference of Teamsters Welfare Fund





























Schedule of Benefits
Benefit Package 140




Date Inquired About: 8/17/2022
Today's Date: 8/17/2022
Effective January 2022


MCTWF
Michigan Conference of Teamsters Welfare Fund (MCTWF)
Benefit Package 140
SCHEDULE OF BENEFITS
 
SOA Medical BenefitBCBS PPO NetworkNon-BCBS PPO Network
Annual DeductibleNoneNone
Annual Out of Pocket Maximum
includes medical copay and coinsurance amounts.

MCTWF complies with the Affordable Care Act out-of-pocket cost limits*
$2,000 per family$4,000 per family
In-Patient Hospital ExpensesCovered 100% of CC after $250 co-payment for up to 365 days semi-private room or private room if medically necessary
Covered 90%** of MAB after $250 co-payment for up to 365 days semi-private room or private room if medically necessary
Hospital Emergency Expenses
   (must meet criteria)
Covered 100% of CC after $75** copay (waived if admitted)Covered 100% of MAB after $75** copay (waived if admitted)
Mental Health & Substance
Use Disorder Benefits

(must receive prior authorization for inpatient services by calling BCBS at 800-762-2382)
Inpatient Hospital:Covered in full after $250 copay per admission.
Inpatient Physician:Covered in full
Outpatient Physician:$20** copay
Inpatient Hospital:Covered 100% of MAB after $250 copay per admission.
Inpatient Physician:Covered 80%** of MAB
Outpatient Physician:Covered 60%** of MAB
Surgical ExpensesCovered 100% of CC
Covered 90%** of MAB
Specified Organ Transplant Program
Expenses
Covered 100% of CC.
Must use a designated facility.
Covered 100% of CC.
Must use a designated facility.
Maternity Expenses
Pre/Post Natal Delivery

Covered 100% of CC

Covered 90%** of MAB
Anesthesia ExpensesCovered 100% of CC
Covered 90%** of MAB
Ambulance Expenses
Ground/Air/Water

Covered 100% of CC

Covered 100% MAB
X-ray and Diagnostic Testing
Expenses

Covered 100% of CC

Covered 90%** of MAB
Laboratory Expenses
  Fluids/Pathology/Diagnostic Tests

Covered 100% of CC

Covered 90%** of MAB
Physician Charges
  Inpatient

  Outpatient Primary Care Visit
  Outpatient Specialist Visit
  Outpatient Urgent Care Visit
  MDLIVE Telehealth Consultation

Covered 100% of CC

$20** co-payment
$20** co-payment
$20** co-payment
$10** copay

Covered 80%** of MAB

Covered 60%** of MAB
Covered 60%** of MAB
Covered 60%** of MAB
Not Covered
Wellness Benefit
  Physical / GYN Exam /
  Well Child Exam


Covered 100% of CC

Covered 60%** of MAB

Wellness Benefit
Pap Smear Screening &
Mammogram Screening


Covered 100% of CC

Covered 90%** of MAB

Wellness Benefit
Child Immunization /
Adult Flu Vaccination


Covered 100% of CC

Covered 80%** of MAB
Injection ExpensesCovered 90%** of CC
Covered 80%** of MAB
Chiropractic Expenses24 spinal manipulations per person annually covered 80% of CC. One mechanical traction per day only with spinal manipulation covered under Physical, Speech & Occupational Therapy Expenses. One "new patient" office visit every 36 months and one "established patient" office visit annually, per chiropractor, covered under Physician Charges - Outpatient/Office Visit.24 spinal manipulations per person annually covered 70% of MAB. One mechanical traction per day only with spinal manipulation covered under Physical, Speech & Occupational Therapy Expenses. One "new patient" office visit every 36 months and one "established patient" office visit annually, per chiropractor, covered under Physician Charges - Outpatient/Office Visit.
Hearing Aid ExpensesCovered 100% of CC, up to $1,500 per person, per ear every 2 years
Covered 100% of MAB, up to $1,500 per person, per ear every 2 years
Outpatient Cancer Treatment
(e.g. chemotherapy & radiation therapy)

Covered 90%** of CC

Covered 80%** of MAB
Physical, Speech &
Occupational Therapy Expenses

Covered 75%** of CC

Covered 65%** of MAB
Home Health Care ExpensesCovered 90%** of CC
Covered 90%** of MAB
Skilled Nursing Facility Expenses100% eligible expenses for room and board and other medical services up to 730 days reduced by 2 times the number of days in hospital
100% eligible expenses for room and board and other medical services up to 730 days reduced by 2 times the number of days in hospital
Hospice Care ExpensesCovered in full
Covered 100% of MAB
Durable Medical Equipment
and Medical Supplies Expenses

Covered 90%** of CC

Covered 90%** of MAB
Prosthetic Devices and
Orthotics Expenses

Covered 75%** of CC

Covered 75%** of MAB
Survivor Health BenefitsProvides up to 36 months of free medical and prescription drug coverage for eligible spouses and dependent children of participants who die while actively covered under a MCTWF medical benefits package. Coverage will mirror the benefits provided to the deceased participant’s MCTWF participating group.Provides up to 36 months of free medical and prescription drug coverage for eligible spouses and dependent children of participants who die while actively covered under a MCTWF medical benefits package. Coverage will mirror the benefits provided to the deceased participant’s MCTWF participating group.
Prescription Drug BenefitCaremark Pharmacy Network
Prescription Drug Rx2Participating Retail: Up to 34 day supply, covered in full after $10 copay for generic and $20 copay for brand name drugs. 90 day supply covered in full after $20 copay for generic and $40 copay for brand name drugs.

Participating Mail Order: Up to 90 day supply. Covered in full after $20 copay for generic and $40 copay on brand name drugs.
Other Benefit(s)Coverage
Benefit Bank WeeksReceive 6 benefit bank weeks for the period of 04/01/2021 through 3/31/2024.***

CC (Contracted Charges) means the agreed upon fees between MCTWF and in-network providers.

MAB (Maximum Allowable Benefit) means the portion of the amount billed by an out-of-network provider that has been established as the benefit package maximum payable amount, subject to deductible, coinsurance and co-payments.

* In accordance with the Affordable Care Act, effective January 1, 2017, all MCTWF Actives Plan medical and prescription drug benefits combined in-network out-of-pocket costs are subject to calendar year limits. Out-of-pocket costs refer to deductibles, copay and coinsurance amounts (but not contribution payments, or out-of-network cost-sharing or balance bill payments). Once a calendar year limit is reached, coverage must be provided for the balance of the year without further out-of-pocket costs for in-network medical and prescription drug benefits. The limits for 2022 are $8,700 per individual and $17,400 per family member accumulations toward these statutory out-of-pocket cost limits are tracked on each MCTWF Explanation of Benefits (EOB) form and in each MCTWF Participant Portal account.
** The co-payments and/or coinsurance payments for these services apply toward the annual out-of-pocket maximum.
*** Participant receives the noted 6 weeks except in cases where a different arrangement was approved by MCTWF, or the participant is contributed on under a MCTWF benefit package with seasonal eligibility requirements, in which case they do not receive benefit bank weeks.

Eligibility for auto-related accidental injuries or illnesses under your MCTWF benefit package will be available only to the extent that claims resulting from the accident are in excess of the greater of (1) the required insurance coverage or other financial protection required under applicable state law, or (2) the benefit limits of any other insurance under which the individual is entitled to coverage. MCTWF will provide benefits pursuant to a signed MCTWF Assignment, Subrogation and Reimbursement Agreement, contingent upon the submission of proof that benefits have been exhausted through the auto carrier and/or other insurance available. MCTWF does not provide Qualified Health Coverage.

If you are the operator or occupant of a rental vehicle and other medical coverage is available, no MCTWF benefits will be paid for auto-related accidental injuries or illnesses.


This Schedule of Benefits is not a full statement of covered services under your benefit package. As a general rule, all procedures or services not deemed experimental by the medical community are covered. Contact MCTWF's Member Services Call Center for any benefit questions you may have.