Your Medical Benefits

FAST FACTS

  • When you visit a UHC provider or facility for medical care, the provider accepts the discounted pre-determined rate for payment. You will need to pay your Patient’s Portion, if applicable.
  • If you do not visit a UHC provider or facility, you are responsible for payment of the balance that the provider charges above the UHC rate in addition to your Patient’s Portion.

Hospitalization:

  • Charges for a semi-private hospital room are covered at 100% of the allowance up to $7,000 per spell of illness.
  • Covered expenses related to a surgery are covered at 80% after you’ve satisfied your annual deductible.
  • You may obtain a second opinion at no cost to help you determine whether or not a surgery is necessary.
  • The anesthesiologist assigned to your surgery may not participate in the UHC network. This means you will have to pay 20% of the allowed amount plus any amount over the allowance.
  • A “physician” is a doctor, chiropractor, podiatrist, psychologist, optometrist, or surgeon licensed to practice medicine or perform surgery under the laws of the state where such services are performed, and who is acting within the scope of his license. A duly licensed practitioner, who, under the supervision of a physician, performs services that would be covered under this Plan if performed by the physician, is also treated as a “physician.”
  • A “spell of illness” is a period beginning when you first are confined in a hospital, nursing home, or other approved facility and ending when you are discharged and:
    • you recover completely from the condition causing the confinement
    •  you go at least one year during which you are not confined again for the same condition
  • An “approved facility” is a legally operated institution, other than a hospital, that provides care and treatment through medical, diagnostic or surgical facilities on the premises, under supervision of a physician and approved by the Board of Trustees. This term may include: ambulatory surgery centers, walk-in medical centers, birthing centers, hospices, substance abuse rehabilitation facilities, acute care facilities, and facilities for the treatment of mental or nervous conditions. A determination by the Board of Trustees as to whether or not an institution constitutes an approved facility is definite.

Home Health Care, Nursing Home Care and Hospice Care Benefits:

  • If prior authorization is obtained, the Plan will pay:
    • 80% of the allowance for covered home health care visits by a registered nurse or licensed practical nurse, after you’ve met your annual deductible
    • 100% of the allowance for visits by a home health care aide
  • If you (or your dependent) are required to stay in a nursing home following hospitalization, the Plan will pay for covered expenses at 100% of the allowance for up to 60 days.
  • Hospice care is covered at 100% of the allowance in a pre-approved facility.

Gynecological Care and Maternity

  • For inpatient maternity and gynecological care, the Plan pays 100% of the allowance for hospital charges up to $7,000. After that, the Plan will pay 80% of the allowance.
  • UHC offers a prenatal education and information program to all EWTF members and spouses called the “Healthy Pregnancy Program,” which qualifies a participant for coverage at 85% of the allowance for the delivery charges of the obstetrician.
  • Annual Wellness Exams for Women are covered at 80% of the allowance after the annual deductible is met.
  • Newborn Wellness Exams prior to discharge from the hospital (or a similar period for delivery outside a hospital) are covered in full, and no deductible applies.
  • Certain prescribed pre-natal vitamins are covered provided that they do not contain mineral supplements. To find out if your prescribed vitamins are covered, call the Fund Office at 301-731-1050 or at 1-800-929-3983.

Understanding Your Medical Benefits

Your Plan provides comprehensive medical coverage for you and your eligible dependents. The Plan participates in the UnitedHealthcare Choice Plus Network (UHC) to provide quality health care, convenience and savings to you, your dependents and to the Plan. 

After you meet your annual deductible, most covered services are paid at 80% of the allowance. You’re responsible for paying the other 20% of the allowance—your Patient’s Responsibility. If you visit a non-UHC provider, you may be responsible for additional expenses as well, including any amount billed by the provider that exceeds the allowance. However, if you receive services from a non-UHC provider under circumstances in which you did not have an opportunity to determine, and were not aware of, the provider’s status as a non-UHC provider prior to receiving the services (for example: emergency room services or anesthesiology services received at a UHC provider facility), then the Plan will treat the billed amount as the allowance and will pay 80% of such allowance. You will be responsible for the remaining 20%.

Advantages of Using the UHC Choice Plus Network

The Plan has contracted with the UnitedHealthcare Choice Plus Network (UHC). This organization works with thousands of the country’s top medical providers, including doctors, medical labs and hospitals. 

When you go to a UHC provider, the provider will: 

  • Agree to accept payment for services directly from the Plan; 
  • Ask members to pay their estimated Patient’s Portion of the allowance at the time of service; and

The Power to Save

Although you are not required to use UHC network providers, you generally will save money by using UHC doctors, hospitals, labs and other providers.

For example: Let’s say David has to go to the doctor to receive treatment. The Plan has determined that the allowance for this service is $200 per visit both in-network and out-of-network. The example below compares what the Plan pays and what David pays in and out-of-network. 

UHC DoctorNon-Participating Doctor
The UHC doctor’s normal charge for this service is $250 The Non-Participating doctor charges $250 for this service
The allowed amount is $200 and UHC doctor accepts this as full payment. The allowed amount is $200, but the Non-Participating doctor still requires $250 as full payment.
The Plan pays 80% of the allowance, or $160The Plan pays 80% of the allowance, or $160
David’s Patient’s Portion is the remaining 20% or $40 David’s co-payment is the remaining 20% of the allowance, or $40, plus the amount over the allowance, or $50.
David’s out-of-pocket costs: $40
David’s out-of-pocket costs: $90

Telemedicine Services

In addition to the in-person medical visit coverage described in this Section, Participants and Dependents also have unlimited, toll-free access or web-based video access to a licensed physician for medical and behavioral health consultations and health information services through Teladoc. Consultations are available on-demand 24 hours a day, 365 days per year and scheduled consultations are available between the hours of 7 a.m. to 9 p.m., seven days a week. To access such services by telephone, please contact Teladoc at 1-800-TELADOC or go to www.teladoc.com. You also may download Teladoc’s secure video-based app on your smartphone, desktop or tablet.  These telemedicine services are available at no cost to you.

Self-Funded Plan

UnitedHealthcare is not your insurance company. The EWTF Plan is “self-funded” private health plan. This means that your employer’s contributions—and any income earned from investments of your employer’s contributions—pay for the health care expenses that you and your fellow participants incur under the Plan. The EWTF Plan makes the final decisions about what is covered and what is paid and EWTF writes the checks to pay benefits.

Provider Directories

For the most up-to-date information about all participating providers call the Fund Office at (301) 731-1050 or 1-800-929-EWTF or visit the UHC website at http://directory.uhis.com or the UHC link on the EWTF website (www.ewtf.org). This is the best way to get a list of all network doctors, hospitals, labs, emergency centers, etc. Be sure to check with your providers before you make a UHC appointment to be certain that they still participate in the UHC network.

Find dental providers by visiting the CIGNA Dental website at www.cigna.com.

EWTF Benefit Card

When you and your family first become eligible in the Plan, you will receive information and an EWTF Benefit Card that identifies you as a network member. You will need to use this card to receive network health care services, prescription drugs and dental care. Your UHC Group Number is 78-340001. The last six digits of the 12 digit number appearing on your card will be used when submitting dental claims or for filling prescriptions at your local pharmacy.

Always identify yourself as an EWTF participant covered by the UHC network by showing your EWTF Benefit Card to any doctor, pharmacy, dentist or other provider you visit. If the provider is a network member, you will start saving money right away.

Out-of-Pocket Maximum (Catastrophic Benefit)

Note: This benefit provided for Standard Plan (full) coverage only; no provision for “H” Plan (limited) coverage. 

The Plan limits the amount of eligible expenses you have to pay each year. Once you have provided written proof to the Fund Office that you have paid the out-of-pocket maximum of $8,000 per family in a calendar year, EWTF will pay 100% up to the allowance of your eligible expenses for the rest of the calendar year. This benefit provides great protection in those situations where an individual or a family may suffer a financial hardship due to a very serious illness or accident. 

What the Out-of-Pocket Maximum Does Not Include

Your annual deductible;

  • Services that are not covered under the Plan (for example, cosmetic surgery, TMJ treatment, fertility/infertility treatments, etc.);
  • Dental and vision expenses; and 
  • Charges above the Plan’s allowance.

Hospitalization and Surgery

The Plan provides coverage for hospitalization and surgery—including organ transplants—for you and your eligible dependents.

What You Need To Do

If you are going to be hospitalized, call UHC at 1-800-850-1418 to have your hospital stay pre-authorized to make sure your expenses are covered to the fullest extent possible.

If your doctor recommends elective surgery, you may contact another physician to obtain a second opinion. 

Hospitalization

Covered Hospital expenses are paid at 100% of the allowance for expenses up to the first $7,000 per spell of illness. A spell of illness is a period beginning when you are first confined in a hospital, nursing home, or other approved facility and ending when you are discharged and:

  • You recover completely from the condition causing the confinement
  • You go at least one year during which you are not confined again for the same condition.

After that, covered hospital expenses are paid at 80% of the allowance. No deductible applies.

Covered Hospital Expenses include charges made by a hospital for:

  • Semi-private accommodations; 
  • Drugs;
  • Use of the intensive care or coronary care unit;
  • Use of the operating room or other specialized facilities;
  • Diagnostic testing; and
  • Other covered ancillary charges.

Pre-Admission Review and Approval through UHC

A part of the Fund’s agreement with UHC is the “utilization” or “pre-admission” review program. When you are going into the hospital, call UHC case management and review services at 1-800-850-1418. Doing so will not only ensure the quality of the services you receive both in the hospital and from your attending physician, but it also can save you hundreds, if not thousands, of dollars in hospital and doctor charges. 

When your doctor schedules a hospitalization for you, the doctor or the hospital will call UHC for information about benefits, eligibility and pre-authorization. Generally, UHC will review the clinical information necessary to determine eligibility for benefit coverage and will verify eligibility and basic benefits for services that meet clinical guidelines for medical appropriateness. The UHC case management service will, if they establish clinical eligibility for coverage, pre-authorize the hospital stay. (Note: This pre-authorization is not a guarantee of coverage under the Plan.) They will then monitor your hospital stay and assist in discharge planning, equipment rental, home health care, and other appropriate services.

The UHC Case Management Program is designed to ensure that in-patient and post-hospital services are covered to the full extent allowed under the Plan. This will help minimize your out-of-pocket expenses and will allow you to take advantage of any discounts offered. The case management service is available nationwide, regardless of whether your doctor or hospital is a member of the UHC network. 

EWTF will not cover hospitalization for a procedure if it is normally provided on an outpatient basis unless UHC approves the hospital stay in advance.

Surgery

The Plan will pay 80% of the allowance, after you’ve satisfied your annual deductible, for charges related to surgery such as:

  • Charges by physicians and surgeons in or out of the hospital (including attending physician, consulting physician, and anesthesiologist);
  • Services of a licensed speech therapist or physiotherapist (prior authorization by UHC is required before beginning any treatment or services);
  • Anesthesia and its administration;
  • Breast reconstructive surgery following mastectomies;
  • Treatment of a fracture or dislocation of the jaw, oral surgery, or treatment of natural teeth, if medically appropriate as the result of, and within 12 months after, an accidental injury;
  • 25% of surgeon’s charges to cover an assistant or co-surgeon; and
  • Emergency medical care expenses.

Outpatient Surgery 

If you or your dependent receives outpatient surgery at an approved facility, the Plan will pay 100% of the allowance for the facility fee up to the first $7,000 in covered expenses. After that, the Plan will pay 80% of the allowance. 

Second Surgical Opinion

To help eliminate unnecessary surgery, you may wish to obtain a second surgical opinion before undergoing elective (non-emergency) surgery. The second opinion must be performed by someone other than your surgeon and not affiliated with your surgeon.

The Plan pays the full cost of obtaining a second surgical opinion. If the first and second opinions differ, the cost of a third opinion is also covered, on the same terms as the second surgical opinion. 

If the second opinion is the same as your surgeon’s, you will have added peace of mind. If the consultant advises you against the operation, you may obtain a third opinion. Regardless of the outcome, if you still want to proceed with the surgery, you are free to do so. The choice is yours.

What’s Not Covered

No benefits are payable in connection with a second surgical opinion relating to the following:

  • A consultation with anyone who is not certified to perform the proposed surgery;
  • More than two consultations with a surgeon after the initial determination, in connection with the proposed surgery;
  • Any consultation with a physician who performs the surgery or has a financial interest in the outcome of the recommendation;
  • Any consultation in connection with a proposed surgery for which a surgical expense benefit would not be payable under this Plan; or 
  • Any consultation unless the patient is examined in person by the surgeon rendering the second opinion.

Please see Specific Plan / Benefits Exclusions and General Plan Exclusions for an in-depth listing of your Plan’s exclusions.

Organ Transplants

The cost of an organ transplant is covered the same as any other surgery, provided the following conditions are met:

  • The transplant procedure is not considered experimental or investigational;
  • Patient screening, including an opinion rendered by a qualified medical professional employed by the Trustees, confirms the appropriateness of the transplantation; and
  • The patient is admitted to a transplant center program at a major medical center approved by the Board of Trustees.

In addition, the UHC network includes Transplant Resource Services, which provide network access to qualified transplant facilities that have high-quality, cost effective transplant care.

Charges for immunosuppressant drugs prescribed in connection with organ transplants are considered medical expenses.

What’s Not Covered

  • Charges for any individual not covered by this Plan; and
  • Charges for a donor covered by this Plan if the charges are not directly related to the transplant procedure itself.

Please see Specific Plan / Benefits Exclusions and General Plan Exclusions for an in-depth listing of your Plan’s exclusions.

Disease Management Program

The Plan provides a Disease Management program to help you and your dependents better manage certain chronic conditions in order to live a healthier life. The Disease Management Program starts with an outreach from the Fund’s disease management provider. Participating in the Disease Management program is completely free, voluntary and confidential. Please contact the Fund office for more information if you or your dependent have a chronic health condition and are interested in participating in the Fund’s Disease Management Program but have not yet been contacted by the Fund or its provider.

Routine Physical Exam for Member and Spouse

You and your spouse are eligible for an annual physical exam. The Plan will pay 80% of the allowance, after you’ve met your annual deductible. NOTE: Medicare-eligible retirees and their Medicare-eligible spouses are entitled to the Routine Physical Exam benefit only if the services are covered by Medicare. The Plan’s annual deductible does not apply to Medicare-eligible retirees.

The Routine Physical Exam also includes coverage (including administration) for Zostavax, a vaccine for the prevention of herpes zoster (shingles). Benefits for this vaccine are paid at 80% of the allowance and are not subject to the annual deductible. NOTE: The Zostavax vaccine benefit is not subject to the annual deductible and is also available to Medicare-eligible retirees and their Medicare-eligible spouse (provided such retirees or spouse are not enrolled in a separate Medicare Part “D” prescription plan).

Child Wellness Visits and Examinations

Your eligible children are covered under this Plan for regular wellness visits and examinations. Your benefit includes the required childhood immunizations. Benefits are paid at 80% of the allowance after you’ve met your annual deductible according to the following maximums:

  • Children from birth through age 23 months for a maximum of seven visits; and
  • Children age two through age 26 for a maximum of one visit per year.

Well Woman

EWTF encourages women to have an annual wellness exam. The Plan provides the following at 80% of the allowance after you’ve met your annual deductible: 

  • One routine pap smear per year and related office visit; and
  • One mammogram per year for women age 35 or older.

Bariatric Surgery

Summary

UnitedHealthcare’s Bariatric Resource Services (BRS) administers this program. Certain criteria determined by BRS must be met prior to a patient having surgery, in order for the surgery to be covered under the Plan.

Bariatric Resources Services (BRS)

BRS is a surgical weight loss solution for those individuals who qualify clinically for bariatric surgery. Specialized nurses provide support through all stages of the weight loss surgery process. The program is dedicated to providing support both before and after surgery. Nurses help with support in preparation for surgery, information and education important in the selection of a bariatric surgery program, and post-surgery and lifestyle management. Nurses can provide information on the nation’s leading obesity surgery centers, known as Centers of Excellence (COE). A COE is a facility that is a top performing, quality bariatric center that delivers improved clinical and economic outcomes.

All authorization for, information about and enrollment for bariatric surgery must be initiated through the BRS Program. Covered participants seeking coverage for bariatric surgery should notify BRS as soon as the possibility of a bariatric surgery procedure arises (and before the time a pre-surgical evaluation is performed) by calling the Bariatric Resource Services program at 1-888 936-7246 to enroll.

Criteria

The Plan covers surgical treatment of morbid obesity, provided all of the following are true:

  • You are over the age of 18 and are physically mature;
  • You have a minimum Body Mass Index (BMI) of 40, or > 35 with at least 1 co-morbid condition present;
  • One (1) surgery is covered per lifetime unless medically necessary complications arise;
  • You must use a UnitedHealthcare BRS Bariatric COE;
  • You must have completed a multi-disciplinary surgical preparatory regimen, which includes a psychological evaluation;
  • You must have completed a 6-month physician supervised diet documented within the last 2 years (the physician supervised diet is not covered by the Plan);
  • Revisions (performed primarily for weight gain) are excluded from coverage under the Plan; and
  • Excess skin removal is not covered under the Plan, unless medically necessary.

Once the criteria are met and it’s time to choose where the patient has the procedure, the case manager will direct the patient to a COE.

Benefit Coverage

The benefit provides for one (1) surgery per lifetime. The all-inclusive maximum lifetime benefit relating to this procedure is $100,000. This includes benefits paid at the normal coverage rate for the surgery plus all procedures and pre- and post-operative expenses but does not include services resulting from complications due to the surgery. After the $100,000 maximum is reached, eligible expenses are covered at 50%.

Questions

Questions that are specifically related to the Bariatric Resource Services program should be directed to 1-(888) 936-7246.

Gardasil

In general, vaccines and immunizations are covered only for patients up to the age of 18. However, in light of the indications of the effectiveness of Gardasil and the benefits of helping to protect against HPV, the benefit applies to all eligible members through the end of their 26th year and dependents through the end of the month in which they reach age 26. Benefits are paid at 80% of the allowance after the annual deductible is met.

Outpatient Medical Expenses

After you meet the annual deductible, the Plan pays 80% of the allowance for outpatient medical expenses required for the diagnosis and/or treatment of an injury or illness.

The following are considered covered outpatient medical expenses:

  • X-ray examinations and diagnostic laboratory and pathology tests; 
  • Radiation therapy, including charges for X-ray, radon, radium and radioactive isotope treatments;
  • Surgical dressing, splints, trusses, braces and crutches;
  • Oxygen and its administration, including the rental of necessary equipment;
  • Blood transfusions, including the cost of blood, blood plasma and plasma expanders;
  • Surgical appliances required to replace or aid natural organs or body parts, including, among others, artificial limbs, eyes, and larynxes, and electronic heart pacemakers; 
  • Rental (or purchase if more cost-effective) of durable medical equipment;
  • Physician services;
  • Services of a licensed speech therapist or physiotherapist (prior authorization by UHC is required before any services or treatment begins);
  • Contraceptive devices not available over-the-counter;
  • Anesthesia and its administration; and
  • Treatment of a fracture or dislocation of the jaw, oral surgery, or treatment of natural teeth, if medically appropriate as the result of, and within 12 months after, an accidental injury.

What’s Not Covered

Please see Specific Plan / Benefits Exclusions and General Plan Exclusions for an in-depth listing of your Plan’s exclusions.

Covered Chiropractic Care

After the annual deductible, the Plan pays for chiropractic care at 80% of the allowance. 

What You Need To Do

After the first 20 chiropractic visits covered by the Fund, you must obtain a referral from your doctor to verify that any chiropractic services are medically appropriate in order for charges to be considered for payment. Then contact the UHC Prior Authorization Department at 1-800-850-1418.

While services such as manual manipulation and electrical stimulation are generally covered if medically appropriate, the administration of services such as the application of hot packs and cold packs and other routine self-care services are not covered.

What’s Not Covered

  • Exercise and wellness regimes and expenses;
  • Physical therapy by a chiropractor unless referred by a medical physician;
  • Hot and cold packs;
  • Routine self-care services;
  • Nutritional supplements; and
  • Care that is not medically appropriate.

Please see Specific Plan / Benefits Exclusions and General Plan Exclusions for an in-depth listing of your Plan’s exclusions.

Home Health Care, Nursing Home Care and Hospice Care Benefits

If you or your dependents require care in a nursing home, a hospice, or care in your home from a registered nurse or licensed practical nurse, the Plan will pay a percentage of covered costs when this type of care is required. These benefits must be pre-authorized in order to be covered under the terms of the Plan.

What You Need To Do

If you are in need of home health care, contact the UHC CARE Program at 1-800-850-1418 for pre-approval. For care in a hospice, call the UHC CARE Program at 1-800-850-1418 to pre-approve the facility. 

Home Health Care

The Plan covers expenses for home health care instead of hospitalization or beginning within 24 hours after discharge from a hospital confinement. The Plan will pay 80% of the allowance for covered home health care visits by a registered nurse or licensed practical nurse, after you’ve met your annual deductible. The Plan will pay 100% of the allowance for home health care visits by a home health care aide.

Covered home health care expenses will be paid, provided that the home health care service:

  • Is required for care or treatment of an injury or illness which resulted in covered medical expenses;
  • Consists of in-home visits by a registered nurse (R.N.) or licensed practical nurse (L.P.N.) or home health care aide under supervision of a Medicare-certified home health care organization; and 
  • Is approved in advance by the UHC Clinical Services Program 1-800-850-1418.

Nursing Home Care

After a hospital stay, the Plan will reimburse for convalescent nursing home expenses up to 50% of the average semi-private room rate charged by the discharging hospital for up to 60 days per spell of illness. 

When combined with hospital expenses for the same spell of illness, covered nursing home expenses are payable at 100% of the allowance up to the maximum benefit of $7,000. Charges that exceed $7,000 combined hospital and nursing home expenses are payable at 80% for the same spell of illness. 

Convalescent nursing home confinement is considered “required” only if it:

  • is ordered by the attending physician;
  • Begins within seven days of discharge from a hospital confinement of at least two days; and
  • Is due to an illness or injury resulting in covered medical expenses.

Hospice Care

The Plan pays 100% of the allowance for hospice care in a pre-approved facility or by an approved hospice care provider for in-home care. Call UHC at 1-800-850-1418 to pre-approve the facility or provider. 

Durable Medical Equipment

Durable medical equipment (DME) is reusable medical equipment such as walkers, wheelchairs, or hospital beds. In general, DME is covered at 80% of the allowance. DME must be medically appropriate and directly related to the treatment of the patient’s particular illness or injury. Limitations may exist on the rental of some DME. Before renting or buying DME, it is recommended that you contact the Fund Office at 301-731-1050 or at 1-800-929-3983 to verify that the equipment is covered.

Gynecological Care and Maternity

Benefits for gynecological and maternity care are payable on the same basis as expenses resulting from an illness. After you have satisfied your annual deductible, covered charges made by a surgeon or a physician are payable at 80% of the allowance. If you have participated in the free “Healthy Pregnancy Program” offered through UHC, benefits are payable at 85% (rather than 80%) of the allowance for delivery charges by the obstetrician. For information about child wellness visits and immunizations, see Your Medical Benefits. Dependent children are not eligible for maternity care. 

“Healthy Pregnancy” Maternity and Pre-Natal Healthy Baby Program

UHC provides a prenatal education and information program to all EWTF members and spouses. The objective of this program is to promote good health for mother and child, and to reduce the incidence and severity of Neonatal Intensive Care Unit needs by identifying high-risk pregnancies and enrolling members into specialized obstetrical case management. The Plan covers allowable delivery charges for the attending obstetrician at 85% (rather than 80%) for those participants who have participated in this “Healthy Pregnancy Program.” 

What You Need To Do

Contact UHC at 800-850-1418 as soon as you or your spouse’s pregnancy is confirmed to receive free pre-natal care information through the “Healthy Pregnancy Program.” If you have any questions regarding maternity benefits or payment of claims, please contact an EWTF Service Representative at (301) 731-1050. 

Maternity

Maternity care expenses for a member or the member’s spouse can include emergency care, charges by physicians and surgeons in or out of the hospital, assistants or co-surgeons, and anesthesiologist’s charges. No maternity coverage is provided for a member’s pregnant child.

Hospital Expenses for Mother/Newborn Child

The first $7,000 of eligible expenses for room and board and other hospital services
are paid in full for both the covered mother and newborn child (100% of the allowance, no deductible applies). For expenses in excess of $7,000, the plan will pay 80% of
the allowance. You must notify the Fund office and enroll your newborn in the Plan within 30 days from birth. No coverage is provided for the newborn child of a covered dependent child.

Obstetrician’s Charges

The physician’s charges are paid at 80% of the allowance after you’ve satisfied your annual deductible. If you participated in the “Healthy Pregnancy Program,” the benefits are paid at 85% once the annual deductible is met.

Charges for global obstetrical/pregnancy services (antepartum care, delivery, and postpartum care) are paid after the birth of the child.

Services of a Midwife

The Plan pays 80% of the allowance for obstetrical services for delivery at home by a midwife. The midwife must be a certified nurse, work through a medically directed service organization and be under the direct supervision of a board certified Obstetrician-Gynecologist throughout pre-natal care, delivery, and during postpartum care. If the services of a nurse-midwife are used, no benefits are payable for charges by an obstetrician unless required due to complications.

Duration of Hospital Stay Following Childbirth

The Plan does not require that a provider obtain prior authorization from UHC or issuer for prescribing a length of stay less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. 

Mastectomy and Breast Reconstructive Surgery

In accordance with the Women’s Health and Cancer Rights Act of 1998, this Plan will provide the following coverage for a Participant or Dependent who is receiving benefits in connection with a mastectomy and who elects breast reconstruction surgery following such mastectomy: 

  • Reconstruction of the breast on which the mastectomy has been performed;
  • Surgery and reconstruction of the other breast to produce a symmetrical appearance; and 
  • Prosthesis and physical complications for all stages of the mastectomy, including lymphedemas.

What’s Not Covered

  • In-vitro fertilization, artificial insemination, or other treatment of infertility, or services to reverse tubal ligation, vasectomy, or other voluntary, surgically induced fertility;
  • Abortions, unless justified by a physician as medically appropriate to protect the life of the patient, or with prior written approval of the Fund Office, when certified in writing by a physician who is board certified in obstetrics and gynecology prior to performing the procedure, that the fetus suffers from a severe performing disability which is likely to seriously affect the quality of life of the child if the pregnancy were carried to term; and
  • Charges incurred by a dependent child in connection with pregnancy, childbirth, miscarriage or related medical condition. 

Please see Specific Plan / Benefits Exclusions and General Plan Exclusions for an in-depth listing of your Plan’s exclusions.