Medical Benefits
***For Full Description of Your Benefits, Please Refer to your Summary Plan Description***
In order to have health coverage for the first time with Local 1298, you must earn 1,000 ST hours in two back to back halves. For eligibility information call the Fund Office at 516-489-3644.
In-Network Benefits- MagnaCare
MagnaCare offers you a choice of Participating (In-Network) Providers. In- Network Health Care Providers have agreements with MagnaCare under which they provide health care service and supplies for favorable negotiated discounted fees for Plan Participants. When you use the services of an In-Network health care provider, you are responsible for paying the applicable copayment for any Medically Necessary services or supplies to the Plan’s limitations and exclusions.
The MagnaCare network consists of more than 70,000 industry-leading healthcare provider locations in the New York and New Jersey area and if you live or travel to another state, you can access over 500,000 healthcare providers through MagnaCare National Access, through First Health Network. This network of physicians covers specialist ranging from internists and other family doctors to various types of surgeons. Additionally, MagnaCare’s networks including hospitals, diagnostic facilities, laboratory facilities and radiology facilities, as well as ancillary providers.
View Insurance related material including your account activity, Plan documents or find a provider, either on your laptop or mobile device via the CREATE app. Use the link below to register or access your account: https://www.mycreatehealth.com
If out of state please utilize the link to find a First Health Network Provider:
https://providerlocator.firsthealth.com/LocateProvider/LocateProviderSearch/
Directories of Network Providers: Physicians and other health care Providers who participate in MagnaCare Network are added and deleted during the year. At any time, you can find out if any provider is a member of MagnaCare by visiting https://www.magnacare.com/provider-locator/ or by calling 1-800-352-6465. Because Health Care Providers are added to and deleted from networks during the year you should call MagnaCare or ask the provider to verify their contracted network status before your visit to assure you will be able to receive their discounted price for the services you need.
Copayments: A copayment (or copay) is a set dollar amount you (not the Plan) are responsible for paying when you incur an Eligible In-Network Medical Expense. For an office visit or clinic visit, the copayment of $30 per visit, however copayment amounts vary. Specific copayment amounts for other in-network services are listed in the Schedule of Medical Benefits (To review the Schedule refer to page 34 in your Summary Plan Description). For example, the copayment for in-network physical therapy is $10.
Deductible: A Deductible in an out-of-pocket expense you are responsible for paying eligible expenses before the Plan begins to pay. A separate $200 In-Network hospital expense Deductible is required for each inpatient hospital admission and certain other expenses covered by the Hospital Benefit. Specific services that require payment of a Hospital expense Deductible does not apply to included services, In-Network medical expenses, Out-of-Network services of any type, prescription drugs and dental and vision expense.
There is no In-Network medical expense Deductible.
Out-Of-Network Benefits
Out-of-Network refers to providers who have not contracted with MagnaCare. Out-of-Network Providers have no agreements with MagnaCare and are generally free to set their own charges for the services and supplies that they provide. These Out-of-Network providers may bill you a non-discounted amount for any balance that may be due over and above the Allowed Amount payable by the Plan, also called Balance Billing. When you choose to receive care from an Out-of-Network provider, the Plan generally reimburses Eligible Medical Expense at 70% and you pay 30% (called co-insurance) of the Allowed Amount AFTER satisfying the Deductible (as described below). As a result, when you use and Out-of- Network provider, you are responsible for the 30% co-insurance, Deductible, and any charges over and above the Allowed Amount (e.g., Out-of-Network providers may balance bill you).
** For more information on Out-of-Network benefits, please refer to pages 29-31 in your SPD **
Under the Plan, Precertification by MagnaCare Medical Management Is required for the following:
Failure to receive precertification will result in non-payment of the bill
For Precertification provider must call: 1-877-335-4725
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All inpatient Hospital admissions
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Ambulatory surgery- Hospital or surgery center
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Durable Medical Equipment (if costs exceed $500)
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Outpatient podiatric surgery
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Homecare
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Hospice
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Skilled nursing facility
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Ambulance-notification required within 24 hours of service
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MRI, MRA, PET & SPECT
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Emergency room
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Physical Therapy- After initial evaluation
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Prosthetics (if cost exceeds $500)
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Occupational Therapy- After initial evaluation
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Outpatient facility based programs (e.g. intensive outpatient and partial hospitalization)
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Residential treatment facilities
This Plan is required to provide certain information on a public website pursuant to the Federal Transparency in Coverage Final Rule published in the Federal Register on November 12, 2020.
The Plan will provide a link, maintained by the Plan’s third party administrator, Magnacare, to a an internet-based self-service tool on its website. This tool is intended to provide participants access to the Plan’s prices charged by the provider, contracted or negotiated rates, consumer cost-sharing obligations and other information. You can use this information before receiving care to compare prices and better estimate potential out-of-pocket costs.
You may receive this information in paper form, upon request. For more information, please contact the Fund Office or visit https://www.cms.gov/healthplan-price-transparency/consumers
This Rule is intended to make information about the prices charged for health care available to the general public, particularly researchers. These experts can use pricing information from this Plan and others to better understand the health care system and its costs and, hopefully, create new policies that improve competition and lower health care spending.
The Rule requires that the Plan post links to machine-readable files that contain information about the price of health care services. A machine-readable file is written in computer code and is an extremely large file. It is not intended to be downloaded or read by participants but to be used in research studies. The files do not contain Protected Health Information (PHI) about you or your family.
Links on this website provide machine-readable files for the Plan’s in-network negotiated rate and historical allowed amounts for out-of-network charges. The files attached to the links are maintained by the Plan’s third party administrator, Magnacare. Magnacare will update the file attached to the links automatically each month.
If you have any questions about the Rule, you can read more information at https://www.cms.gov/newsroom/fact-sheets/transparency-coverage-final-rule-fact-sheet-cms-9915-f
All machine readable info here : https://clm.magnacare.com/transparency
Under the Plan, Precertification is required for the following services and may be obtained by calling
Workforce Assistance at 914-417-5355.
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Mental Health services, for inpatient admissions, admissions to residential treatment facilities and outpatient facility-based treatment (e.g. intensive outpatient and partial hospitalization)
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Substance/Alcohol Abuse services for inpatient admissions, admissions to residential treatment facilities and outpatient facility-based treatment (e.g. intensive outpatient and partial hospitalization)
When you need care for mental health or substance/alcohol abuse disorders, you have a choice of providers: you may use in-network or go out-of-network.
Workforce Assistance provides Participants and their eligible Dependents with intervention referral services, personal case management and continued follow-up services for mental health, alcohol and substance use disorder treatment. When you call Workforce Assistance, a qualified representative will help find and refer you to treatment.
**For more information on precertification, please refer to pages 24-25 in your SPD**
HeartScan Services
This preventive screening program focuses on identifying early stages of heart, carotid (stroke), thyroid cancer (nodules), Aortic Aneurism and peripheral arterial disease (early diabetes and hypertension).
The New Screening program- A non-invasive screening takes approximately 45 minutes and no preparation is required. Heartscan Services will perform the screening in their Levittown office, making it convenient for all participants to take advantage of this program. Heartscan Services is HIPPA compliant and all results are strictly confidential.
To schedule your appointment for you and your spouse, please contact Heartscan Services at 1-866-518-1112.