| 一般承保医疗福利 | Coverage (100% up to Funds fee allowance, after applicable Copayment) **每个计划的共同支付金额有所不同. 请参阅共同支付时间表，了解您的计划的共同支付金额 |
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| 医院住院, 包括半私人房间, 重症监护室或冠状动脉监护室, 肾透析, 精神疾病, 酒精/化学品依赖和生育. | Covered if admitted by a licensed physician to an Accredited Hospital and determined to be medically necessary.
医疗保险 beneficiaries must have services approved by 医疗保险 Part A. 医疗保险A部分是主要支付者. Non-医疗保险 beneficiaries must have services approved by the Funds’ Precertification Department at 1-800-292-2288. |
| Outpatient Hospital, including emergency medical, accident, surgical care, 实验室 & x-ray, chemotherapy, radiation therapy, physiotherapy, and 肾透析. | 如有医疗需要，承保.
医疗保险 beneficiaries must have services approved by 医疗保险 Part A. 医疗保险A部分是主要支付者. |
| 医生的服务, 包括手术护理, 助理外科医生, 产科/交付, 麻醉, 紧急救治。, 实验室 & x-ray, radiation, chemotherapy, consultations, podiatry, primary care and specialist care. | 如有医疗需要，承保. |
| 专业护理机构 | Covered if admitted by a licensed physician to a licensed skilled nursing care facility and is medically necessary.
监护/非技术护理不包括在内.e. 洗澡、家务、日托) Must be a 医疗保险 approved Skilled Nursing Facility and must have a qualifying hospital stay prior to admission. 医疗保险 beneficiaries must have services approved by 医疗保险 Part A. 医疗保险A部分是前100天的主要付款人. 皇冠搏彩中心网站将在此期间支付A部分共同保险. 在医疗保险的前100天用完之后, the Funds will become the primary payer if the level of care is skilled. Precertification is required for days in excess of the 100 day maximum. Non-医疗保险 beneficiaries must have services approved by the Funds Precertification Department at 1-800-292-2288. |
| Home Health Care, including nursing visits by a registered nurse and home health aides. | 如果在医生的照顾下，可以投保, condition requires skilled nursing care or speech/physical therapy at least once every 60 days, 医生治疗计划是存在的, 病人只能呆在家里.
需要得到皇冠搏彩中心网站预认证部门的批准 1-800-292-2288. 医疗保险受益人-医疗保险A部分是主要付款人. |
| 物理(PT)及言语治疗(ST) | Covered when prescribed by a physician to restore functions lost or reduced by illness or injury. 当受益人达到他或她的恢复潜力时, 这些服务不再包括在内.
医疗保险 beneficiaries are subject to the 医疗保险 cap on outpatient PT and ST. Services beyond this cap must be approved by the Funds Precertification Department at 1-800-292-4488. Non-医疗保险 beneficiaries must have services approved by the Funds’ Precertification Department at 1-800-292-2288. |
| 耐用医疗设备(DME)和用品 | 承保租金或, 在适当的地方, 在医生确定有医疗需要时购买.
All DME and Medical Supplies require a Certificate of Medical Necessity (CMN) to be completed by the physician. All beneficiaries are required to use one of the seven Funds Network DME vendors. 供应商必须为任何超过300美元的DME物品获得预认证. 租金上限期限为15个月，适用于所有租金. Incontinence supplies, such as adult diapers and chux are covered, limited to 3 boxes per month. 每个福利每月最高可达150美元. |
| 氧气 | 由主治医生下令投保, patient is referred to a designated pulmonary consultant for testing and the consultant’s report is submitted to the Plan administrator with the order for oxygen.
The 15 month Rent-to-Cap period applies to all oxygen equipment rentals. 氧气需要预先认证，并且必须每年重新认证. Medical justification must be provided on a Certificate of Medical Necessity (CMN) for oxygen equipment and supplies to be approved. 还需要提供其他文件. |
| 假肢和矫形装置 | 由医生开具处方并在医学上必要时投保. |
| 预防保健 | Routine physical examinations are covered for: Newborns and children up to age 6, 55岁及以上, 现有的医疗状况和正在接受医生治疗, 接受妇科医生的年度或半年度检查, or undergoing routine exam prescribed by a specialist as part of such specialist’s care of a medical condition.
American Medical Association (AMA) guidelines are utilized for covered visits. If in excess of guidelines, claims will suspend for medical review. 为免疫接种提供福利, 过敏脱敏注射, 巴氏涂片, 筛查高血压和糖尿病, 癌症检查, blindness and deafness and other screening and diagnostic procedures when medically necessary. 1993/Pre-Funded Plans – Age limit does not apply to 医疗保险 eligible beneficiaries. CBF/1992计划-年龄限制不适用于任何受益人. |
| 非紧急运输 | Covered with prior approval from the Plan Administrator if for ambulance transportation to or from a hospital, 诊所, 医疗中心, 医生办公室或专业护理机构, 当医生认为医学上有必要时.
Benefits are avai实验室le if the medical care is not avai实验室le near the beneficiary’s home and the beneficiary must be taken out of area, 或者如果受益人需要频繁的运输, 比如用于放射或物理治疗. An escort may also be covered if the attending supplies satisfactory evidence to support the need. Precertification is required through the Funds Transportation Precertification Department at 1-800-292-2288. Non emergency ambulance transportation for scheduled trips to receive medical care is provided only for patients that are bed confined or can only be moved by a stretcher to the ambulance. 定期旅行的替代交通方式(i.e. Ambulette, 范, 出租车, 航天飞机, or bus) will be approved only if assisted transportation is medically necessary and beneficiary would otherwise require ambulance transportation. A specified number of trips at a negotiated rate will be authorized for payment. 受益人和陪同人员的食宿可由保险公司承担, 如果事先批准, 用于区外运输. |
| 助听器 | Services must be provided by an approved hearing aid vendor who has signed a Hearing Aid Vendor agreement and is on the approved list of 29 providers.
Hearing aids over $600 require precertification through the Funds Hearing Aid Precertification Department at 1-800-292-2288. 必要的维修和保养福利, 除了更换电池, 保修期结束后还会提供吗. Benefits will be provided for replacement hearing aids only if a new aid is needed because of a change in the beneficiary’s condition, 或者助听器不能正常工作了. |
| 按摩保健 | 医疗保险 beneficiaries have a chiropractic benefit through 医疗保险. 医疗保险不包括脊柱手术.
的资金 will process these claims as a 医疗保险 benefit at 80% of 医疗保险 allowable. 的资金 will not pay the 医疗保险 co-insurance since chiropractic care is not covered by the Funds benefits plan. 对于非医疗保险受益人，这不是一个覆盖的福利. |
| 常规视力护理 | 作为有限的福利. Benefits are provided once every 24 months up to a maximum amount for each service.
报销金额见视力费用表. Lenses will not be covered unless the new prescription differs from the most recent one by an axis change of 20 degrees or .50 diopter sphere or cylinder change and the lenses must improve visual acuity by at least one line on the standard chart. |
