Hospital Benefits (Including Mental Health and Substance Abuse)
HOSPITAL BENEFITS AT-A-GLANCE
|In-network Coverage Only (Except for Emergencies)||Plan I||Plan II|
BlueCard PPO/Beacon Health Options
BlueCard PPO/Beacon Health Options
$100 per admission;
$100 per admission;
90% of Contract Rate
80% of Contract Rate
10% of Contract Rate
20% of Contract Rate
Coinsurance Out-of-pocket Limit
$1,750 per person;
$2,000 per person;
*TIHN benefits are not available for emergency room care.
The Plan uses the national BlueCard PPO network (through a contract with Anthem Blue Cross of California) and The Industry Health Network (TIHN) for all Hospital benefits except mental health and substance abuse care. The Plan uses the Beacon Health Options network for mental health and substance abuse benefits. Out-of-network hospital services are covered only in the event of an emergency. See the following page for a description of emergency treatment and when coverage for services from Out-of-network Providers may be available.
Annual Hospital Deductible
Hospital charges are subject to an annual Deductible based on the calendar year. The Hospital Deductible is separate from the Deductibles for the other benefits provided by the Plan, such as the medical, prescription drug and dental Deductibles.
As outlined in the table on the previous page, the amount of the Hospital Deductible varies depending on which network you use and whether you are covered under Plan I or Plan II.
The family Deductible is satisfied when at least two or more family members have combined Covered Expenses that exceed the amount of the family Deductible in a calendar year. However, the Plan will not apply more than the individual Deductible amount to any one family member. For example, if a Plan I Participant has a spouse and a child who each have a BlueCard PPO Hospital stay in the same year, the $500 family Deductible is satisfied once the family has paid a total of $500 in Covered Expenses. However, the Plan will not apply more than $250 (the amount of the individual Deductible) toward the Deductible for either the spouse or the child.
The Plan applies Covered Expenses toward your Deductible as it processes Claims, rather than according to the date of service. Providers submit their Claims in accordance with their own billing schedules, and Claims are frequently received out of order with regard to date of service, particularly when multiple Providers are used.
If you go to a Hospital for emergency treatment, your Deductible is based on the BlueCard PPO Deductible. This Deductible applies even if you called or visited TIHN first and they told you to go to the emergency room. The Hospital deductible for TIHN applies only to non-emergency Hospital care received through TIHN facilities.
If your eligibility changes from Plan I to Plan II during a calendar year, any charges that applied toward your Deductible under Plan I will apply toward your Plan II Deductible. If your eligibility changes from Plan II to Plan I during a calendar year, the reverse is also true.
Copays, Coinsurance and Out-of-Pocket Limits
There is a $100 Copay required when you use the Hospital as an inpatient, for outpatient surgery, or in the emergency room. Once the Copays and Deductible are satisfied, the Plan provides reimbursement of Covered Expenses from in-network Hospitals based on the percentage shown in the table on the previous page. You are responsible for the Coinsurance amount.
The Coinsurance out-of-pocket limit is the maximum amount you and your family could pay for Covered Expenses during a calendar year after your Deductible and Copays are satisfied. For example, a single Plan I Participant who has met his or her Hospital Deductible and Copays is responsible for 10% of the first $17,500 of covered in-network Hospital expenses during the year, or $1,750 as Coinsurance.
When you have paid your Deductible and the maximum Coinsurance amount, the Plan will reimburse 100% of Covered Expenses for the remainder of the year, with the exception of Hospital Copays. Your total in-network out-of-pocket expenses are also limited by the comprehensive out-of-pocket maximum described on the previous page.
If your eligibility changes from Plan I to Plan II during a calendar year, any charges that applied toward your Coinsurance out-of-pocket limit under Plan I will apply toward your Plan II out-of-pocket limit. If your eligibility changes from Plan II to Plan I during a calendar year, the reverse is also true.
Emergency Care Under the Hospital Benefit
An emergency is the sudden and unexpected onset of an injury or illness that is acute and that could reasonably be expected by a prudent layperson to result in serious medical complications, loss of life, permanent impairment to bodily functions or permanent dysfunction of a body part in the absence of immediate medical attention. Examples of emergencies include but are not limited to, uncontrolled bleeding, seizures or loss of consciousness, shortness of breath, chest pains or severe squeezing sensations in the chest, suspected overdose of medication or poisoning, sudden paralysis or slurred speech, burns, cuts and broken bones.
Emergency treatment at in-network and out-ofnetwork Hospitals is covered within 72 hours after an accident or within 24 hours of a sudden and serious illness.
The Hospital Copay applies when you visit the emergency room. Only one Copay will apply if you are hospitalized immediately for the same accident or illness.
If you are admitted to an out-of-network Hospital due to an emergency, you or the Hospital should call the applicable network listed below within 48 hours to report the emergency admission and request authorization for coverage.
- For an emergency admission to a Hospital for medical care, call Anthem Blue Cross at (800) 274-7767.
- For an emergency admission to a Hospital for mental health or substance abuse treatment, call Beacon Health Options at (866) 277-5383.
Covered Hospital Benefits
he Plan’s Hospital benefits cover facility charges for medical and surgical treatment as well as mental health and substance abuse treatment. Like medical and surgical treatment, mental health and substance abuse treatment is covered for a vast number of conditions. Among them are anxiety, stress, eating disorders, depression, bipolar disorders, psychosis, schizophrenia and substance abuse (alcohol and/or other drugs). If you have a question about a particular condition and whether coverage is provided:
- For medical or surgical treatment, contact the Plan at (800) 777-4013.
- For mental health or substance abuse treatment, contact Beacon Health Options at (866) 277-5383 or www.achievesolutions.net/sag-aftra.
The Plan’s Hospital benefits include coverage for the services listed below.
- Emergency treatment for services which are billed by the Hospital and listed on its statement of charges. Any services that are not included on the Hospital bill and are billed separately, such as Physicians’ or surgeons’ charges, may be covered under the medical benefits. Urgent care center charges may also be covered under the medical benefits.
- In-network alternative levels of mental health and substance abuse care:
- Residential treatment center – Treatment that is provided in a 24-hour non-medical facility.
- Partial Hospital program – Treatment that is provided for 6 – 8 hours per day.
- Intensive outpatient program – Treatment that is provided for 2 – 3 hours per day.
- In-network birthing centers. Charges for out-ofnetwork birthing centers may be covered under the medical benefits.
- In-network outpatient Hospital treatment for diagnostic services and therapy such as x-rays, imaging tests, physical therapy and chemotherapy.
- Inpatient hospice care provided by an in-network Medicare-certified hospice program, when an individual is terminally ill with a life expectancy of less than 12 months. Hospice benefits are not subject to the Deductible. Outpatient hospice care may be covered under the medical benefits.
- Outpatient surgery in an in-network Hospital, surgical suite or ambulatory surgical center, including charges for services connected with surgeries that are billed by the facility. Services not billed by the facility and charges at an out-of-network surgical suite or at a surgical center may be covered under the medical benefits.
- Semi-private room, board, Hospital services and supplies for acute care for a covered diagnosis at in-network Hospitals. For stays in a private room, the Plan pays the in-network Hospital’s most common semi-private room rate. You are responsible for the difference between the private and the semiprivate room rates.
In-network Hospital services and supplies considered for coverage include the following:
- Administration of blood or blood plasma (the actual charge for blood is covered under the medical benefits).
- Cardiac testing.
- Drugs and medicines.
- Intensive care.
- Medical supplies and devices, splints, casts and dressings.
- Operating, delivery, treatment and recovery rooms.
- Physiotherapy and hydrotherapy.
- Special diets.
- Staff nursing care.
- X-rays, imaging tests, laboratory exams and pathology exams.
Hospital Stays for Delivery of a Child and Maternity Care
A Hospital stay related to childbirth, miscarriage, ectopic pregnancy or premature termination of pregnancy is only covered if the patient is a Participant or the spouse of a Participant. A newborn’s ordinary nursing care in the Hospital is also covered, but only if the newborn is the Participant’s dependent. For pregnant Dependent children, only Hospital charges for treatment in connection with complications of pregnancy are covered. Complications of pregnancy do not include the elective termination of a pregnancy.
For any Hospital stay in connection with childbirth, in accordance with federal law, the Plan does not restrict inpatient stay benefits to less than 48 hours following a vaginal delivery or less than 96 hours following a Cesarean section. However, federal law generally does not prohibit the mother’s or the newborn’s attending Physician from discharging the mother or her newborn earlier than 48 hours (or 96 hours, if applicable) if the mother and newborn are healthy, and after consulting with the mother.
In any case, the Plan does not require that a Provider obtain authorization from the Plan for prescribing a length of stay that does not exceed 48 hours (or 96 hours, for a Cesarean section).
Non-Covered Hospital Expenses
The following are not covered under the Plan’s Hospital benefits:
- All expenses for out-of-network Hospital services, except for emergency treatment as described on the previous page.
- A stay in a facility or Hospital that is not registered as a general Hospital by the American Hospital Association and does not meet accreditation standards of the Joint Commission on Accreditation of Hospitals, except for facilities that provide alternative levels of care for the treatment of mental health and substance abuse as outlined on the previous page.
- A stay primarily for diagnostic tests, pulmonary tuberculosis, convalescent care, rest or Custodial Care.
- A stay primarily for physical or rehabilitative therapy. If a patient is transferred to a Hospital’s rehabilitation wing (either from the same acute care Hospital or from another acute care Hospital), and the care is still considered acute care, the Plan may consider benefits.
- Care that is covered under other Plan benefits, such as ambulance, blood and blood plasma, x-ray or radiation therapy, special braces, appliances or equipment, or outpatient care.
- Christian Science homes or sanitariums.
- Convalescent facilities.
- Charges in connection with Cosmetic Surgery, except under the limited circumstances.
- Out-of-network birthing centers (limited coverage is provided under the medical benefits).
- Outpatient hospice care (covered under the medical benefits).
- Personal comfort items, such as a television or telephone.
- Physician’s surgical suite or an out-of-network surgery center (limited coverage is provided under the medical benefits).
- Private duty nursing for care that would normally be provided by the Hospital’s nursing staff.
- Services provided by Physicians, surgeons or anesthesiologists not employed by the Hospital (covered under the medical benefits).
- Services of technicians and other vendors not employed by the Hospital.
- Skilled nursing facilities. If a patient is transferred to a skilled nursing facility from an acute care Hospital and the care is still considered acute, the Plan may consider benefits.
- Urgent care centers (covered under the medical benefits).