Teamsters Local 805 Welfare Fund

SUMMARY PLAN DESCRIPTION -

HOSPITALIZATION AND MAJOR MEDICAL BENEFITS

This Section describes your Hospitalization and Major Medical benefits, including the PPO networks offered by the Fund. The Fund's reimbursement levels and your out-of-pocket expenses vary depending on whether you use network or out-of-network providers, so please read this Section carefully.

A. NETWORK AND NON-NETWORK COVERAGE

i. Network Coverage
An important aspect of this Plan is the use of Preferred Provider Organizations (PPOs). These PPOs have established networks of hospitals, physicians, radiologists and laboratories that have agreed to provide all covered services to you with only a small out-of-pocket cost.

The Fund has contracted with the GHI Physician and Hospitalization Network to make available a network of physicians, hospitals and other health care providers at a reduced cost to you and the Fund. If you choose an Aetna physician, you do not have to pay any deductible and are responsible only for a $20 co-payment for each physician visit.

Each participant will receive an GHI Card and Directories to assist you in locating network providers in your area. NOTE: Although the directory is updated periodically, please contact GHI or the Fund office for up-to-date information if you want to locate a physician or confirm that your current physician is in the GHI Network.

Each contracting provider has agreed to provide all covered service at limited out-of-pocket cost to our Participants. From time to time the Fund may contract with other organizations in the Fund's efforts to bring you the best and most cost-effective health coverage that can be afforded.

ii. Out-of-Network Coverage
You also have the choice of using Physicians, Hospitals and other health care providers outside the GHI Networks. If you use an out-of-network provider for physician and outpatient services covered under the Fund's Major Medical provisions, the Fund will pay up to 70% of the Reasonable and Customary Charge for such services after you have paid the applicable Annual Deductible and subject to the Fund's maximum benefit limitations

B. HOSPITALIZATION BENEFITS

i. Amount of Coverage
Except as otherwise provided, the Plan will pay 100% of the Negotiated Charge if you are hospitalized in a participating GHI Hospital. Payment for services rendered by Hospitals that are not members of a contracted PPO will be paid at 100% of the Reasonable and Customary charges. This benefit is not subject to the Deductible.

ii. Covered Days of Care
The Plan will pay for covered hospital services for a maximum of 365 days of inpatient hospitalization for one or more consecutive hospital confinements ("Covered Days"). If you use all 365 days, another 365 days will become available after at least 90 days pass since the last date of covered inpatient hospitalization. The 90-day waiting period does not apply to Hospital confinements for an unrelated cause or diagnosis. This benefit is subject to the annual maximum benefit limitation.

iii. Certification for Hospital Admissions
If the admission is a non-urgent admission, you must get the days certified by calling the number shown on your ID card. This must be done at least 14 days before the date the person is scheduled to be confined as a full-time inpatient. If the admission is an emergency admission or an urgent admission, you, the person’s physician or the hospital must get the days certified by calling the number shown on your ID card. This must be done:

• Before the start of confinement as a full-time inpatient which requires an urgent admission; or
• Not later than 48 hours following the start of a confinement as a full-time inpatient which requires an emergency admission; unless it is not possible for the physician to request certification within that time. In that case, it must be done as soon as reasonably possible. (In the event the confinement starts on Friday or Saturday, the 48 hour requirement will be extended to 72 hours.)

If, in the opinion of the person’s physician, it is necessary for the person to be confined for a longer time than already certified, you, the physician or the hospital may request that more days be certified by calling the number shown on your ID card. This must be done no later that on the last day that has already been certified.

Written notice of the number of days certified will be sent promptly to the hospital. A copy will be sent to you and to the physician.

iv. Bed, Board and General Nursing Care
Semi-private Accommodations: If you are a hospital patient in a semi-private room, your bed, board (including special diets) and general nursing care are covered as set forth above for Covered Days.

Private Accommodations: If you occupy a private room, you will receive a daily allowance equal to the hospital's average semi-private room charge toward the cost of bed, board and general nursing care for Covered Days.

v. Other Hospital Services
The following services are covered as set forth above regardless of the class of accommodations occupied, if they are necessary for the diagnosis and treatment of the condition for which you are hospitalized:

• General nursing care;
• Use of operating and cystoscopic rooms;
• X-ray examinations (not including X-ray therapy) consistent with the diagnosis and treatment of the condition for which hospitalization is required;
• Drugs and medicines for use in the Hospital (not including radium or radioactive isotopes) which are commercially available for purchase and readily
• obtainable by the Hospital;
• Use of cardiographic equipment;
• Anesthesia supplies and use of anesthesia equipment;
• Oxygen and use of equipment for its administration;
• Dressing and plaster casts;
• Use of physiotherapeutic equipment; and
• Basal metabolic equipment.

vi. Maternity Care
Maternity benefits are provided for expenses incurred in a hospital for a Participant or a Participant's spouse or dependent on the same basis as for any other Illness or Injury. Regular hospital benefits will be provided for hospital stays involving any pregnancy-related condition, whether or not pregnancy is terminated.

The Newborns' and Mothers' Health Protection Act of 1996 provides that a plan may not restrict benefits for any hospital length of stay in connection with childbirth for a mother or newborn child to:

1) less than 48 hours following a normal vaginal delivery, or
2) less than 96 hours following a caesarean section.

However, Federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours, as applicable). In any case, a plan may not require that an attending provider such as your physician obtain additional authorization for prescribing a length of stay within these limits.

This law requires that the Fund disclose the above information concerning impermissible restrictions on maternity care. You should be assured, however, that this Plan has no such restriction.

vii. Newborn Children
Under family coverage, benefits are available from birth for:

• The treatment of Illness or Injury;
• Nursery care in an approved premature unit for an infant weighing less than 2,500 grams (5.5 pounds);
• Incubator care, regardless of the infant's weight; and
• Routine nursery care.

viii. Emergency Treatment
The $75 co-payment is waived if you are admitted as an inpatient for Emergency Treatment. Regular hospitalization benefits are provided when you are not admitted as an inpatient but receive care in a Hospital's emergency room or operating room for:

1. Emergency first aid during the first visit for treatment of an Injury within 24 hours following such Injury, or
2. Emergency care during the first visit for treatment within 72 hours of the onset of sudden and serious Illness, or
3. Minor emergency surgery.

NOTE: The emergency room is for emergencies only. The Fund will apply the rules as described above in determining whether an emergency existed. The key to determine when to use the emergency room is if your medical condition is "sudden and serious". If the Fund rejects an emergency room visit based upon a determination that it was not an emergency, the Fund will pay the claim under the Major Medical provisions as a Physician's office visit.

ix. Pre-surgical Testing
Diagnostic tests prescribed by your Physician and completed in the Hospital as a preliminary to scheduled inpatient surgery.

x. Home Health Care – In-Network Only
Home Health Care benefits are available under a Home Health Care Plan when such treatment is Medically Necessary and pre-authorized by the Fund Office. Services must be rendered through a New Jersey or New York State-certified Home Health Care Agency. Benefits will be provided only if hospitalization or confinement in a skilled nursing facility would otherwise have been required.

Covered services: Services of a registered graduate nurse (R.N.) or licensed practical nurse (L.P.N.) for private duty nursing services when Medically Necessary and prescribed in writing by the attending Physician or surgeon specifically as to duration and type.

The Plan will pay 100% of the Negotiated Charge by an in-network provider.

Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health aid is one visit. Maximum of 200 visits per calendar year.

Limitations to Home Health Care Expenses

This benefit does not cover charges made for:

• Services or supplies that are not a part of the home health care plan,
• Services of a person who usually lives with you or who is a member of your or your spouse’s family,
• Services of a social worker, or
• Transportation.

NOTE: You must obtain prior authorization from the Fund for Home Health Care Coverage.

xi. Hospice Care – In-Network Only
Hospice in-patient benefits are available under a Hospice Care Program for up to 90 days in a Hospice Care Facility. The Plan will pay 100% of the Negotiated Charge. If you do not obtain prior approval from the Plan, You will not receive benefits.

xii. Mental or Nervous Disorders and Substance Abuse
Hospital benefits for Mental or Nervous Disorders and Substance Abuse treatment are excluded under this Plan. If you do not obtain prior approval from the Plan, You will not receive benefits.

xiii. Physical Therapy, Physical Medicine and Rehabilitation
Regular Hospital benefits are provided for up to 30 days during a calendar year for stays or portions of stays primarily for physical therapy, physical medicine, and rehabilitation, when such services are performed under programs approved by the appropriate State Department of Health and pre-authorized by the Fund office.

xiv. Skilled Nursing Facility - In - Network Only
You must obtain prior authorization from the Plan for coverage of admission to a Skilled nursing Facility. If you do not obtain prior approval from the plan, you will not receive benefits.

The Plan will cover up to a maximum of 60 days for a pre-approved admission to a Skilled Nursing Facility for patients recovering from a disease or injury.

A Skilled Nursing Facility is covered when:

• The confinement is recommended by a doctor and begins during a convalescent period
• The patient is under the continuing care of a doctor
• The patient receives necessary:
  • Skilled nursing care
  • Physical rehabilitation services, or
  • Both, and
  • It is expected that the care received will improve the patient’s condition and facilitate discharge.
• A Skilled Nursing Facility qualifies for coverage under the Plan if the facility is recognized as a skilled nursing facility by Medicare.

C. HOSPITAL EXCLUSIONS
In addition to the General Exclusions listed on page 49, benefits are not paid for:

1. Confinement for sanitarium-type, custodial or convalescent care, or for rest cures; or for care in a Hospital or long-term care;
2. Services of Physicians or private or special nurses, or other private attendants or their board;
3. Care in an institution, which does not usually bill and collect charges from patients;
4. Expenses incurred during confinement in a Hospital owned or operated by the Federal Government, unless required by law;
5. Hospital stays or any part of a Hospital stay primarily for diagnostic studies, mental, nervous and substance abuse; and
6. Hospital services for dental care, treatment, surgery or appliances usually performed by a dentist, except as expressly provided under the dental benefits program.

D. MAJOR MEDICAL BENEFITS
Major Medical benefits provide for coverage for Hospital, medical and surgical care in excess of the Hospitalization benefits, including Physician visits, x-ray and laboratory charges, surgery, anesthesia and other medical services and supplies that the Fund determines to be Medically Necessary.

i. Network Coverage
If you use an GHI provider, your out-of-pocket costs for expenses covered under the Fund's Major Medical provisions are limited to a $20.00 co-payment. Directories are available to assist you in locating network providers in your area. In addition, you may visit the GHI website for more information at: http://www.ghi.com.

ii. Out-of-Network Coverage
If you use a non-network provider, you are responsible for satisfying the Annual Deductible before the Fund will begin to pay benefits. The Annual Deductible is $300 for individuals and $750 (combined) for a family for each calendar year. The Fund will pay 70% of Reasonable and Customary charges for covered Major Medical expenses provided by a non-network provider after you have paid the Annual Deductible. You are responsible for any remaining expense.

iii. Deductible-Calendar Year Deductible
A deductible is the amount of eligible Major Medical charges that will be deducted before any Major Medical benefits are paid by the Fund. The amount applied to your deductible is the amount that the Plan recognizes as a covered charge.

Each calendar year, a Deductible of $300.00 for each Active Employee or dependents will be applied to all Major Medical services rendered by non-network providers. The annual Deductible will have a family limit of not more than $750.00 per family.

iv. Physician Visits
Services rendered by Physicians and surgeons, including specialists, for the care or treatment of Illness or non-occupational Injuries is covered at set forth above, depending on whether you use an GHI provider or a non-network provider.

This service is paid at 100% after a $20 co-payment In-Network and at 70% of Reasonable and Customary Charges, Out-of-Network, after annual deductible. The participant pays the difference.

v. Laboratory and Radiological Diagnostic Services
Diagnostic services such as laboratory tests, X-rays, sonograms, Cat-scans, and MRI tests are all covered services.

These services are paid at 100% when performed by network providers - NO co payment - and at 70% of Reasonable and Customary charges, subject to the annual deductible, when provided by Out-Of-Network providers.

The 100% coverage for network providers only applies when you use an Aetna diagnostic facility. These facilities have a separate listing in the GHI directory and are not the same as the list of Aetna hospitals. Check the directory for the “Diagnostic Providers” for the 100% coverage.

vi. Well-Baby and Well-Child Care
Well-Baby Physician visits are covered according to the following schedule:

This service is paid at 100% after a $20 co-payment In-Network and at 70% of Reasonable and Customary Charges Out-of-Network, after annual deductible. The participant pays the difference.

vii. Inoculations
Generally, infants are given the DPT and Polio inoculations at ages 2 months and 6 months. Additionally, a booster shot is given at approximately age 18 months. All inoculations required by the State school system in which the child is enrolled through college are covered. The Fund will pay for the office visits associated with administering these inoculations, plus the wholesale cost of the inoculation. If a separate office visit is needed for the measles, mumps and rubella vaccines, this visit will be covered at the same rate.

If you use an In-Network provider, coverage is provided at 100% of the Negotiated Charge. If you use an Out-Of-Network provider the Fund will pay 70% of the Reasonable & Customary charges after the Deductible is met.

viii. Annual Physical
One annual physical is available to all Participants each calendar year. In addition, female Participants are covered for a separate annual gynecological examination, including Pap smear and mammogram.

This service is reimbursed at 100% of the Negotiated Charge if you use an In Network provider and at 70% of Reasonable & Customary after a co-payment if you use an Out-Of-Network provider. Not subject to the annual Deductible.

ix. Ambulance Services
Emergency transportation by ambulance is covered to the Hospital.

This service will be paid for at either the Negotiated Charge for Network providers or 70% for Out-Of-Network providers. This benefit is not subject to the annual Deductible. Transportation home from the Hospital is not a Covered Charge.

x. Mental and Nervous Disorders
Outpatient Mental and Nervous Disorder benefits are available up to a maximum of 40 sessions per calendar year when rendered by a licensed psychologist, psychiatrist or social worker.
This service is covered In-Network only at 100% after a $20 co-payment.

xi.Out-Patient Substance Abuse (Drug & Alcohol Treatment)

xii. Physical Therapy, Occupational Therapy and Other Specialized Therapies and Diagnostic Tests
Physical therapy, occupational therapy and other specialized therapies and diagnostic tests are covered services under the following conditions. A Letter of Medical Necessity must be submitted and pre-approved prior to such services being rendered.

Physical and occupational therapy services are covered up to a maximum of 30 visits as an inpatient. There is no co-payment for in-network services. Outpatient services are covered At 70% of the reasonable and customary after the deductible is met.

xiii. Chiropractic Services
Chiropractic services are covered up to a maximum of 30 visits per person per calendar year. Services are reimbursed at 100% less the co-payment for network providers and at the 70% for Out-Of-Network providers after the annual Deductible has been met. Chiropractic claims are limited to two modalities per session. The term modality refers to the hot packs, electric stimulation and other like services commonly performed by chiropractors.

ix. Durable Medical Equipment – In-Network Only
The Fund will pay for the rental or purchase (whichever is more cost effective as determined by the Fund) of durable medical equipment. Durable medical equipment providers have a separate listing in the GHI book. Durable medical equipment is equipment or supplies designed for prolonged use, which is primarily and customarily used only to serve a medical purpose; are prescribed by a Physician; are Medically Necessary and; are generally useful to a person with an Illness or Injury, such as a wheelchair, Hospital bed, etc. Only equipment recognized and approved as covered equipment by Medicare will be reimbursable under this benefit. This benefit is covered in-network only.

E. SURGICAL AND ANESTHESIA BENEFITS

i. Surgical Expenses
Charges for surgery performed by GHI providers are covered at 100% of the Negotiated Charge for all non excluded services. No co-payment applies to surgical procedures done by Network Providers. Charges for surgery performed by Out-Of-Network licensed physicians are covered for all non excluded services at 70% of the Reasonable and Customary charges subject to the deductible. When two or more surgical procedures are done, in the same operating area, the Reasonable and Customary fee of the most expensive procedure will be allowed as the R&C allowance, and each subsequent procedure will be reduced by 50%. The term “operating area” in this instance will mean in the same incision.

ii. Assistant Surgeon
If the services of an assistant surgeon are required and the Hospital does not provide one, benefits are payable for services of a surgical assistant at 25% of the Reasonable and Customary charge of the surgery. Out-Of-Network services are subject to the annual deductible.

iii. Anesthesia
This service is covered at 100% of Reasonable and Customary charges, or at the Negotiated Charge, whichever is applicable. This benefit is not subject to the deductible.

F. THE WOMEN’S HEALTH AND CANCER RIGHTS ACT

The Women’s Health and Cancer Rights Act of 1998 (“WHCRA”), provides that any group health plan or health insurance issuer that provides medical and surgical benefits with respect to a mastectomy must also provide coverage for reconstructive surgery following the mastectomy. If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the WHCRA. For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

• All stages of reconstruction of the breast on which the mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearances;
• Prostheses; and
• Treatment of physical complications of the mastectomy, including lymphedemas.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this plan. If you would like more information on WHCRA benefits, call your Plan Administrator, Roderick Gorham, at (718) 609-6401.

G. MAJOR MEDICAL EXCLUSIONS

In addition to the General Exclusions set forth on page 49, the following services and supplies are NOT covered by the Fund's Major Medical benefits:

• Air conditioners, air-purification units, humidifiers and electric heating units,
• Dental services and other services of a type usually performed by a dentist (These services may be covered under the Plan’s dental benefit described on pages 51-53),
• Eye examinations for obtaining eyeglasses (These services may be covered under the Plan’s optical benefit described on page56).

i. Routine Physical Exam Expenses That Are Not Covered:

• Services which are covered to any extent under any other part of this Plan;
• Services which are for diagnosis or treatment of a suspected or identified injury or disease;
• Exams given while the person is confined in a hospital or other place for medical care;
• Services not given by a physician or under his or her direction;
• Medicines, drugs, appliances, equipment or supplies;
• Psychiatric, psychological, personality or emotional testing or exams;
• Exams in any way related to employment;
• Premarital exams;
• Vision, hearing or dental exams;
• Services rendered in connection with hospitalization primarily for bed rest, sanitarium care, or occupational rehabilitation therapy psychiatric confinement, or convalescent nursing homes;
• Non-specific injection therapy;
• Specialist consultations in the fields of roentgenology, pathology, and anesthesia;
• Private duty nursing in the Hospital; unless Medically Necessary and pre-authorized by the Fund;
• Common first-aid supplies such as adhesive tape, gauze, antiseptics and ace bandages, etc.;
• Non-prescription drugs;
• Reversal of a sterilization procedure;
• Transsexual operations or any care or services associated with this type of operation;
• Biofeedback therapy;
• Any and all telemetric services or patient operated diagnostic tests;
• Podiatry expenses are not covered – orthotics; casting, fabrication and dispensing of orthotics; surgical shoes or dispensing thereof; surgical trays and sterile packs; outpatient operating room fees; fees for surgical assistant; pre-and post-op x-rays and serial x-rays during surgery; * injection of local anesthetic* are not covered.