ILWU-PMA Benefit Plans

This is not a complete description of the benefit provisions of each health plan. The information provided here and in the Supplemental Summary Plan Description booklets is subject to, and in no way modifies or interprets the provisions of the ILWU-PMA Welfare Agreement and the provisions of policies of insurance and contracts between the Welfare Plan Trustees and the insurance carriers and providers of care. Printer friendly version
ILWU-PMA Coastwise Indemnity Plan	Group Health Cooperative
The Plan pays for benefits under a Basic Benefit Schedule of Allowances plus Major Medical with an annual deductible of $100 individual/$300 family. Covered benefits are paid in accordance with the Basic Benefit Schedule at 100% with any remaining balance paid under Major Medical: in PPO Network at 100% of charges (no deductible); out of Network at 80% of UCR after deductible; for those not assigned to a PPO Area 100% of UCR (no deductible). Major Medical Lifetime Maximum is $2,000,000. Mental Health Outpatient visits 1 through 20 covered same as any other illness, visits 21-50 covered at Basic Benefit plus $10.00 per visit under Major Medical.	Group Health Cooperative (GHC) is a group practice plan which provides all members services at GHC or GHC-designated facilities (except for out-of-area emergency care and authorized referrals). Benefits are provided at 100% of covered charges at no cost to the member.
Covered Services Include but not limited to: •Hospital Benefits – Room and Board •Surgery/Anesthesia – Surgeon, Anesthesiologist, Asst. Surgeon •Newborn Nursery Care •Doctor Visits – Office visits, Home visits, Hospital visits •Diagnostic X-Ray and Laboratory – Inpatient/Outpatient •Physical Therapy, Occupational Therapy, Speech Therapy •Mammogram, Pap Smears, and Prostate Special Antigen (PSA) Tests	Covered Services Include but not limited to: •Hospital Benefits – Room and Board •Surgery/Anesthesia – Surgeon, Anesthesiologist, Asst. Surgeon •Newborn Nursery Care •Doctor Visits – Office visits, Home visits, Hospital visits •Diagnostic X-Ray and Laboratory – Inpatient/Outpatient •Physical Therapy, Occupational Therapy, Speech Therapy •Mammogram, Pap Smears, and Prostate Special Antigen (PSA) Tests
Other Benefits: •Skilled Nursing Facility Maximum 100 days per Plan Year PPO – 100% of PPO semi-private room rate Non-PPO – 80% of UCR semi-private room rate.	Other Benefits: •Skilled Nursing Facility No Charge
•Hospice Care – 100% up to UCR for all covered services up to 90 days. Also 90 days for bereavement.	•Hospice Care – No charge
•Mental Health Benefits Inpatient – covered under Basic and Major Medical Benefits Outpatient (Maximum 50 visits per Plan Year) - 1st 20 visits: PPO – 100% of PPO rate Non-PPO – 80% of UCR charges plus Major Medical benefit Next 30 visits: PPO and Non-PPO are covered at the basic plan doctor visit allowance plus $10 per visit under Major Medical.	•Mental Health Benefits Inpatient – up to a maximum of 45 days per calendar year Outpatient – up to 20 visits per calendar year. After 20 visits member pays in full
•Alcohol and Drug Dependency Treatment – Up to 5 days of inpatient treatment for detoxification only and up to 20 outpatient visits – Alcoholism/Drug Recovery Program (ADRP) through Welfare Plan	•Alcohol and Drug Dependency Treatment Inpatient – No charge Outpatient – up to $13,000 in any 24 consecutive month period or Alcoholism/Drug Recovery Program (ADRP) through Welfare Plan
•Vision Benefits – Provided through Vision Service Plan	•Vision Benefits – Provided by Group Health Cooperative
•Prescription Drugs – Provided through Prescription Solutions $1 co-payment (The $1 co-payment is waived for mail order prescriptions)	•Prescription Drugs – Provided by Group Health Cooperative – No co-payment
•Annual Physical Exam – Adults PPO – 100% of PPO charges for exam and related lab/x-ray charges Non-PPO – 80% of UCR for exam and related lab/x-ray charges (annual maximum $400) No PPO Access – 100% of UCR for exam and related lab/x-ray charges	•Annual Physical Exam – Adults – No charge as provided under Group Health Cooperative’s Well-Adult prevention age schedule
•Routine Physical Exam – Children *Other Than Infants* – Three exams provided up to age 19 according to a schedule PPO – 100% of PPO rate Non-PPO – 80% of UCR charges No PPO Access – 100% of UCR charges for exam and related lab/ x-ray charges	•Routine Physical Exams – Three exams provided up to age 19 according to an age schedule
•Injectables - Up to 100% of UCR charges for prescribed immunization materials and therapeutic agents administered by injection.	•Injectables – No charge for most immunizations and vaccinations.
•Chiropractic Benefit - Chiropractic Benefits are provided when medically necessary. Effective 07/01/2003 - Limit 40 visits per Plan Year (except where the Welfare Plan Chiropractic Consultant decides additional benefits are medically necessary).	•Chiropractic Benefit - Medically necessary chiropractic benefits are administered by the Coastwise Claims Office based on the ILWU-PMA Welfare Plan’s Chiropractic Benefit provisions. There is the GHC chiropractic benefit – maximum 10 visits per year – with a GHC provider, which, if utilized, is integrated with the Welfare Plan’s chiropractic benefit.
•Durable Medical Equipment - Benefits based on ILWU-PMA Welfare Plan’s Durable Medical Equipment provisions.	•Durable Medical Equipment – Benefits based on Group Health’s Durable Medical Equipment provisions.
Medicare Eligible The Supplemental Plan pays the deductibles and co-payments not paid by Medicare for covered services, and pays the difference, if any, between Medicare allowed charges and UCR charges for Hospital, Medical and Surgical services, as follows: 1. The Medicare Part B Annual deductible amount 2. The 20% coinsurance amount not paid by Medicare, and 3. The difference, if any, between the Medicare allowable charge and the UCR charge	Medicare Eligible Medicare eligible members receive the same benefits as an active member. Medicare eligible members must enroll in Medicare+ Choice and receive all services at GHC or GHC-designated facilities.