MENTAL OR NERVOUS DISORDERS

Regular hospital benefits are available in an accredited Joint Commission on Accreditation of Hospitals (JCAH) non-governmental general hospital, psychiatric hospital or in the separate psychiatric division of a general hospital, which is included in the 120 days hospital maximum.

PHYSICAL THERAPY, PHYSICAL MEDICINE AND REHABILITATION

Regular hospital benefits are provided in hospital for up to 30 days during a 12-consecutive month period for stays or portions of stays primarily for physical therapy, physical medicine, and rehabilitation, when such services are performed under programs approved by the New York State Department of Health. These days are included in the 120 day maximum hospital benefit.

DIALYSIS FOR KIDNEY FAILURE

Regular hospital benefits are provided for hemodialysis or peritoneal dialysis while the Participant is a registered inpatient. Benefits are also provided for outpatient dialysis, as follows:

• In the home – The Plan will pay the cost of all appropriate and necessary supplies required for home dialysis treatment, as well as the reasonable rental cost of the required equipment
• In a hospital or freestanding facility – The Plan will pay the cost of necessary treatment if the facility’s dialysis program is approved by the appropriate governmental authorities

These dialysis benefits will be available until the patient becomes eligible for coverage under Medicare, but the maximum availability is 30 months from the date of the first treatment.

MASTECTOMY BENEFITS

When a participant or beneficiary receives benefits from the Plan in connection with a mastectomy, the plan will also provide coverage for:

• reconstruction of the breast on which the mastectomy was performed
• surgery and reconstruction of the other breast to produce a symmetrical appearance and
• prostheses and physical complications at all stages of mastectomy, including lymphedemas

This coverage is subject to all of the Plan’s rules regarding benefits, including the Plan’s annual deductibles and co-payment provisions.

INPATIENT CARE

When You are admitted to any legally constituted general hospital, You receive the benefits described in this booklet.

OUTPATIENT CARE

When You use a hospital’s facilities for a surgical operation, regular hospital benefits are provided for such care.

HOSPICE CARE

A covered Participant has coverage for up to 210 days of inpatient hospice care in a hospice or hospital, and home care and outpatient services provided by the hospice as described below if:

• the Participant has been certified by his or her primary attending physician as having a life expectancy of six (6) months or less
• the hospice care is provided by a hospice organization certified pursuant; to Article 40 of the New York Public Health Law; or if the hospice is located outside of this state, under a similar certification process required by the state in which the hospice organization is located

Typically, covered hospice and outpatient services include:

• Inpatient care, either in a designated hospice unit or in a regular hospital bed, and day care services provided by the hospice organization.
• Home care and outpatient services provided by the hospice and charged to You by the hospice are also covered. The services may include the following:
  • intermittent care by an R.N. or Home Health Aide
  • physical therapy
  • speech therapy
  • occupational therapy
  • respiratory therapy
  • social services
  • nutritional services
  • laboratory examinations, X-rays, chemotherapy and radiation therapy when required for control of symptoms
  • medical supplies
  • drugs and medications prescribed by a physician and which are approved under the U.S. Pharmacopoeia and/or National Formulary (not covered when the drug or medication is of an experimental or investigative nature)
  • medical care provided by the hospice physician
  • five visits for bereavement counseling for the Participant’s family, either before or after the Participant’s death
  • durable medical equipment (rental only)
  • transportation between home and hospital or hospice organization when medically necessary

HOSPITAL EXCLUSIONS

Hospital benefits are not provided for:

• Confinement for sanitarium-type, custodial or convalescent care, or for rest cures; or for care in a hospital for long term care
• Hospital confinements or any period of hospital confinement primarily for diagnostic studies
• Workers’ Compensation cases; hospitalization furnished under federal, state or other laws, or military service-related care in a veterans facility or a hospital operated by the United States Services of physicians, private or special nurses, and other private attendants or their board
• Any expense, or portion thereof, for which mandatory automobile no-fault benefits are recovered or recoverable
• Participants who have Medicare as primary coverage or are eligible for Medicare coverage; except for the Medicare deductible and any required co-payments up to the maximum hospital benefit

PRE-CERTIFICATION PROGRAM

Surgery is serious. When You have a choice, You must be pre-certified by MagnaCare for the surgery.

All infusible drugs administered in a doctor’s office must be pre-certified.

To arrange for pre-certification, call 1-877-335-4725 as soon as surgery is recommended by Your physician. This does not apply to Participants on Medicare.

HOSPITAL REVIEW PROGRAM

Why is a Hospital Pre-Admission Certification Program necessary?
Costs for health care have escalated in the last decade. The majority of these expenses are for services in the hospital.

The Trustees believe that it is important that You continue to be able to obtain hospital care, when necessary, without compromising the quality of that care. By assuring You that a hospitalization is necessary and that Your hospital stay is not prolonged beyond the time medically required, You will also be helping to keep down the rising cost of health care.

What is Hospital Pre-Admission Certification (PAC) and Continued Stay Review (CSR)?
Hospital Preadmission Certification (PAC) requires You to have Your proposed hospital stay reviewed by MagnaCare professional staff prior to Your hospital admission. Based on information provided by Your doctor, MagnaCare will determine whether Your hospitalization is medically necessary or if the treatment might be provided in a different setting. At the same time it will assign an initial number of approved hospital days and notify You, Your physician and the hospital. This program does not apply to members on Medicare.

What happens if I need more hospital days than were initially approved? (CSR)
When the initially approved hospital days are up, MagnaCare will contact Your doctor to learn if You will be discharged or if Your physician feels that an extension of Your hospitalization is required. If the MagnaCare reviewers agree, additional days will be approved.

What should I do when my doctor recommends admission to a hospital for either myself or an eligible dependent?
You should call MagnaCare immediately (Toll Free) at 1-877-335-4725. Be sure to have the following information on hand: the name and social security number of the participant, the name and identification number of the Fund, the name and phone number of Your doctor, the name of the hospital where You will be treated, the date You are planning to enter the hospital and the planned surgical or diagnostic procedure.

What about urgent or emergency hospital admissions where there is no time to go through the Precertification process?
When You require an URGENT admission Your doctor should telephone MagnaCare at 1-877-335-4725 and give them the information so that they can assign an initial approved number of hospital days.

When You are hospitalized for an EMERGENCY, the doctor or a responsible family member must call MagnaCare within 72 hours to notify it of the hospital admission.

Why should I want to use the Hospital Pre-Admission Certification Program?
You will receive maximum benefits if You use the program.

If You do not use the program, one of the following circumstances will occur:

1. If the admission would have been approved by MagnaCare as medically necessary, You will be subject to a $200 benefit reduction
2. Any admission that would not have been approved as medically necessary by MagnaCare, will not be a covered expense and You will be responsible for 100% of the non-covered charges

What is Large Case Management?
MagnaCare will also provide a special mandatory service designed to assist patients with serious illnesses or injuries. Many people who have used this kind of service have found that it provides valuable assistance and peace of mind during difficult periods of serious illness or injury. Serious medical cases include:

• Chronic illnesses
• Acute catastrophic injury
• Infectious disease
• Burns
• Terminal illnesses
• Neonatal complications
• AIDS and AIDS-related cases

A case management coordinator will contact You and Your family to discuss Your medical care needs. Your personal case management coordinator will help You by:

• Facilitating all activities and communication among the professionals involved in Your treatment plan,
• Providing information about Your treatment options,
• Identifying any needed additional medical resources that may be available to You.

You should take advantage of this valuable case management service in order to assure that services are provided at the appropriate (and least costly) level of care.