PHBP - Plan Changes - July 2019

Dear Participant:

We write to advise you of benefit changes for active and non-Medicare retired participants and eligible dependents in the Pension, Hospitalization and Benefit Plan of the Electrical Industry - Welfare Plan (the “Plan”). These changes apply retroactively, which means that you may be eligible for a refund from the Plan for certain items or services that you paid for after October 1, 2016, as described below.  These changes do not apply to Medicare-eligible retirees.

Changes in coverage for certain preventive care:

The Plan will cover certain preventive medical items, services or prescription drugs without any co-payment, if provided by network providers. The covered items and services include an annual physical exam and preventive screenings, such as mammography; preventive medications such as statins; and many other items and services, for example, folic acid supplementation and breast feeding interventions. These preventive benefits are subject to limitations based on age, frequency, and other criteria.

For a complete list of preventive items or services that will be covered without any co-payment, as well as any limitations that apply, visit the HealthCare.gov website at  https://www.healthcare.gov/coverage/preventive-care-benefits/. You may also find a copy of this notice with a link to the HealthCare.gov website on the Joint Industry Board website at www.jibei.org/phbpchanges. Co-payments will still apply for items and services that do not appear on the list or where the limitations apply.

Annual Out-of-pocket limits:

Each covered individual’s annual out-of-pocket costs for essential health benefits provided by network providers are limited, for the current plan year, to $7,350, and families’ out-of-pocket costs may not exceed $14,700.  A list of essential health benefits that are offered by the Plan is included on page 2.

 The out-of-pocket limits apply to each individual within a family, as well as to the family as a whole.  For example, in a family of three, if one family member incurs $8,000 in eligible out-of-pocket costs in the current plan year, those costs will be capped at $7,350.  The Plan will pay 100% of the in-network charges for any additional essential health benefits that person receives for the rest of the Plan year.  If the other two family members each incur $3,350 in eligible expenses, the family will have reached the $14,700 family maximum.  From that point, the Plan will pay 100% of the in-network charges for any additional essential health benefits that anyone in the family receives for the rest of the year.

Approved clinical trials:

The Plan will cover routine services for participants in approved clinical trials that are pre-certified by MagnaCare.

Retroactive Reimbursement:

As a result of the changes described above, you may be entitled to reimbursement for certain amounts that you paid for the period of October 1, 2016 through present.  Reimbursement will be limited to expenses related to items described above that the Plan is now covering retroactively. This means that MagnaCare and Express Scripts will reimburse any co-payments you paid for eligible preventive items and services on or after October 1, 2016, and will also reprocess denied claims for eligible preventive items and services received during the same period. If you are eligible for reimbursement you should receive payment by December 31, 2019.

If you have any questions concerning preventive prescription drugs, please call Express Scripts at 1-800-818-0883.

If you have any questions concerning preventive medical items or services, please call MagnaCare at 1-877-624-6210.

Sincerely,
Trustees of the Pension, Hospitalization and Benefit Plan of the Electrical Industry        

 ESSENTIAL HEALTH BENEFITS

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Pregnancy, maternity, and newborn care
  • Mental health and substance use disorder services
  • Prescription drugs
  • Rehabilitative services
  • Laboratory services
  • Preventive services and chronic disease management
  • Pediatric services

Preventive Health Services

https://www.healthcare.gov/coverage/preventive-care-benefits/

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