MEDICAL BENEFITS
Private Duty Nursing Care – Annual Per Participant
$20,000.00
All Essential Medical Benefits:
Annual per Participant incl. Hospital Benefits
Unlimited
Deductible Amount
Per Person: $400 per calendar year.
The Fund will pay 80% of Covered Expenses in excess of the Deductible Amount for any covered injury or sickness.
Any Covered Expenses which You or a Dependent incur which are applied toward Your deductible during the last 3 months of a Calendar Year will be applied toward the deductible for the next Calendar Year. If You exceeded the deductible for the year, there will be no application toward the deductible for the next Calendar Year.
Benefits Payable
For Injury or Sickness:
The maximum amount of out-of-pocket expense per person per Calendar Year for those expenses payable at 80% is $3,000 including the Deductible Amount. After the $3,000 has been satisfied the Plan will pay for such person 100% of the balance of the covered expenses incurred for the remainder of the Calendar Year.
The maximum amount of out-of-pocket expense per family per Calendar Year for those expenses payable at 80% is $6,000 including the Deductible Amount. After the $6,000 has been satisfied the Plan will pay for the family 100% of the balance of the covered expenses incurred for the remainder of the Calendar Year.
If You or Your Dependent Incur Covered Expenses as the result of an accidental bodily injury or Sickness during any Calendar Year, benefits will be payable as indicated in the Schedule of Benefits.
ALCOHOLISM AND/OR SUBSTANCE ABUSE TREATMENT
Outpatient/Inpatient benefits for the diagnosis and treatment of alcoholism and/or substance abuse are available to each covered person, subject to the $400 per person per calendar year deductible and the expenses payable at 80%. Family counseling is available to all the persons covered in the patient’s family. Benefits for family counseling are limited to one visit a day.
Within New York State, care for alcoholism is only covered at facilities certified by the New York State Division of Alcoholism and Alcohol Abuse and care for substance abuse is only covered at facilities certified by the New York State Division of Substance Abuse Services.
Outside of New York State, care must be provided by a facility with a treatment program approved by the Joint Commission on Accreditation of Hospitals.
Benefits are provided for covered services rendered in government facilities unless no charge would have been made in the absence of this coverage.
Covered providers are M.D., Ph.D., MSW, CFW, CAC and CFS.
ORGAN TRANSPLANT BENEFITS
Benefits are available for kidney, cornea, and some other transplants, if performed in properly qualified facilities. Coverage for heart, heart-lung, pancreas, bone marrow and liver transplant procedures includes all medically necessary hospital, medical, surgical or other services related to the transplant. Prior authorization must be obtained from the Fund, and the transplant must take place at a facility approved by the Fund for the specific transplant procedure being performed.
Under these conditions, coverage will include:
- all medically necessary care
- costs directly related to the donation of an organ used in the transplant procedure, such as the surgical procedure necessary to procure the organ, storage expenses and transportation costs, up to a maximum of $35,000 per transplant
- reasonable travel expenses if You live more than 75 miles from the transplant center, including food and lodging for the recipient and one adult family member (two, if the recipient is a minor); to the city where the transplant takes place, up to a maximum of $150 per day, $10,000 per lifetime The benefit period begins five days prior to surgery and extends for a period of up to one year from the date of surgery.
ENDOSCOPY AND COLONOSCOPY PROCEDURES
Endoscopy and Colonoscopy procedures will be covered only if performed in a doctor’s office or a free standing surgical center, unless the doctor certifies that it is medically necessary for the test to be performed in a hospital or a hospital surgical center.
ANNUAL PHYSICAL EXAM BENEFIT
Participants and dependents with primary coverage through this Fund are eligible for an annual physical exam, performed in accordance with standard medical protocol. However, the exam must be provided by a MagnaCare participating doctor and all related diagnostic tests must be performed by a MagnaCare participating provider.
When the above conditions are met, the physical exam will be considered a covered expense, subject to the MagnaCare co-payment.
WELL CHILD CARE
Well child care benefits are available for all required immunizations and well care as recommended by the American Academy of Pediatrics.
IMMUNIZATIONS
All immunizations may be subject to additional charges for giving the vaccine depending on where you receive it.
- Influenza immunization is a covered benefit.
- Pneumonia immunization is covered when medically necessary.
- Shingles Vaccine is covered for Participants age 60 and over.
MAMMOGRAPHY BENEFITS
Upon receipt of satisfactory proof, benefits shall be payable for expenses incurred for mammography screening for You or Your Dependent as follows:
- A Mammogram at any age for women having a prior history of breast cancer or whose mother or sister has a prior history of breast cancer, whenever a mammogram is recommended by a physician
- A single baseline mammogram for women age 35 through 39
- A mammogram once every Calendar Year for women age 40 and older
Mammography screening means an x-ray examination of the breast using dedicated equipment, including x-ray tube, filter, compression device, screens, films and cassettes, with an average glandular radiation dose less than 0.5 rem per view per breast.
This benefit will be subject to all provisions applicable to laboratory tests or diagnostic x-ray services under the Plan.