Table of Contents

  1. Medical Benefit Overview
  2. Deductibles
  3. Payment Percentages
  4. Out-of-Pocket Maximums
  5. Maximum Benefit
  6. Preventative Care
    1. Routine Physical Exams
    2. Breast Cancer Chemoprevention
    3. Colorectal Cancer Screening
    4. Adult Immunizations
    5. Childhood Immunizations
    6. Tobacco Use Intervention
    7. Lab and X-Ray (Preventative)
    8. Hepatitis C Screening
    9. Lung Cancer Screening
  7. Diagnostics, X-Ray, Lab (DXL)
  8. Common Medical Services
  9. Special Limitations
    1. Outpatient Speech Therapy
    2. Non-Surgical TMJ Treatment
    3. Jaw or TMJ Surgery
    4. Chiropractic Care
    5. Home Health Care
    6. Hearing Care
    7. Skilled Nursing Facility Care
    8. Hospice Care

Medical Benefits

Your comprehensive Major Medical Benefit is designed to substantially cover most forms of medically necessary care. This coverage is subject to various deductibles, copayments, coinsurance, and other limits.

About the Plan

The medical plan is a Preferred Provider Organization (PPO) plan, administered by Blue Cross Blue Shield, Blue Card PPO (BCBS). On a PPO plan, you can receive care from in-network or out-of-network providers. When you use in-network providers, you'll pay less for care.

Find a Provider

SPD link

  • Deductibles

    Once you meet the annual deductible, the Plan pays 80% of most in-network covered services. In-network providers have agreed to accept the contracted BCBS rate as the total allowed amount for covered services, meaning that you will not be billed for the difference.

    Note that certain specified benefits are not subject to the deductible. Only covered expenses apply to the deductible.

    Individual Deductible: $400.00 per calendar year

    Family Deductible: $1,200.00 per calendar year

    Hospital certification noncompliance: $250 per admission Note: This does not count towards calendar year deductible.

    Emergency room: $150 for each occurrence of hospital emergency room treatment Note: Deductible is waived if the patient is admitted as an inpatient.

    SPD link

  • Payment Percentages

    The percentage of the charges that the plan pays for most covered expenses after the deductible(s) have been satisfied. You pay the remaining percentage of the charges (that portion is called your percentage coinsurance). For more specific information, see the SPD.

    Covered services provided by PPO providers and covered prescription drugs not purchased through the Prescription Drug Mail Service Program:

    Before out-of-pocket maximum is met - 80%
    After out-of-pocket maximum is met - 100%

    Chiropractic care - 50% up to a calendar year maximum benefit of $600

    Covered services provided by non-PPO providers:

    Before out-of-pocket maximum is met - 70%*
    After out-of-pocket maximum for all other covered medical expenses is met - 100%*

    Chiropractic care - 50% up to a calendar year maximum benefit of $600*

    * Note: For out-of-network providers, the allowable charge is the reasonable and customary amount (commonly referred to as the R & C). LINECO's allowable charge / reasonable and customary amount for out-of-network providers is determined based on prevailing Medicare reimbursement methodology and rates.

    SPD link

  • Out-of-Pocket Maximums

    Once you reach your calendar year out-of-pocket maximum, the plan will pay 100% of covered expenses during the rest of that year.

    Per person, unless the person is eligible for Medicare - $2,500
    Per person, if the person is eligible for Medicare - $1,625
    Per family - $7,500

    Note that the following does NOT count towards the out-of-pocket maximum: hearing care, any non-covered services, any amounts over reasonable and customary allowances charged by a non-PPO provider.

    SPD link

  • Maximum Benefit

    Calendar Year Maximum Benefit Payable - unlimited per person covered for essential health benefits*.

    * See summary plan description for special limitations.

  • Preventative Care

    Benefits for covered preventive services are paid at 100% when you use a Blue Cross Blue Shield (BCBS) PPO provider and at 70% if you use an out-of-network (non-PPO) provider. No deductible will apply to covered PPO preventative expenses, but the calendar year deductible will apply to non-PPO preventative expenses. (To find a BCBS PPO provider, go to http://www.bcbsil.com, or call 1-800-810-BLUE [2583].)

    The services covered under this benefit are based on the following recommendations and may change from time to time:

    • United States Preventive Services Task Force (services/items with a rating of A or B by this task force);
    • Immunizations recommendation from the Advisory Committee on Immunization Practices (ACIP) and adopted by the Centers for Disease Control and Prevention; and
    • With respect to infants, children, adolescents and women, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA)

    Partial list of the preventative services covered under this benefit are listed below:

    SPD link

    • Routine Physical Exams

      Routine physical exams will be covered under the Preventive Care Benefit at a frequency of one per year for covered adults and children ages 3 and older. For children under age 3 the frequency of covered exams is determined using guidelines supported by the Health Resources and Services Administration (HRSA).

    • Colorectal Cancer Screening

      Screening for colorectal cancer (adults age 45-75) will be covered under the Preventive Care Benefit within the age and frequency guidelines established by the American Cancer Society (which recommends that persons at average risk should have an initial colonoscopy at age 45), including bowel preps, colorectal exams, flexible sigmoidoscopies, barium enemas, and colonoscopies.

    • Adult Immunizations

      Most adult immunizations (for employees, retirees, and spouses) will be covered under the Preventative Care Benefit.

    • Childhood Immunizations

      Childhood Immunizations will also be covered under the Preventative Care Benefit. Children 0-18 will receive 100% coverage for both in- and out-of-network providers. Older children (19-25) will receive 100% coverage for in-network and 70% after the deductible is met for out-of-network.

    • Tobacco Use Intervention

      For adults 18 & up as needed. The plan covers one tobacco use intervention session every 12 months and certain physician-prescribed tobacco- cessation agents: Chantix limited to 180-day supply/12-month period, and other medications limited to 90-day supply during a 12-month period.

    • Lab and X-Ray (Preventative)

      Lab and x-ray charges related to covered preventive care are covered under the preventative benefit. Other such charges are covered under the DXL benefit (see below).

    • Lung Cancer Screening

      Adults with a history of cigarette smoking are covered for a low dose CT scan once per calendar year.

  • Diagnostics, X-Ray, Lab (DXL)

    100% up to $150 per calendar year (no deductible)

    If you have more than $150 in covered diagnostic x-ray and lab services in a calendar year, the remainder will be considered under the provisions of the Comprehensive Benefit.

    The DXL benefit covers Employees, Retirees, and Spouses only. Preventive/routine lab and x-ray charges are not covered under the DXL Benefit, but under the Preventive Care Benefit instead.

    SPD link

  • Common Medical Services

    Click the SPD link below for specific information about the many common medical services that the Plan covers under the Comprehensive Medical Benefit.

    SPD link

  • Special Limitations

    Unless stated otherwise, the Plan payment percentages for the following types of treatment are as shown under Plan Payment Percentages above. However, expenses for hearing care will NOT be paid at 100% even if your out-of-pocket maximum has been met. Details on specific limitations are specifed on the Schedule of Benefits.

    Refer to the SPD for specific plan guidelines on the benefits below.

    SPD link

    • Jaw or TMJ Surgery

      Lifetime maximum benefit per person for TMJ surgery that is: (a) out-of-network, or (b) in-network but not precertified - $3,000. Other jaw surgery is covered as a regular medical benefit.

    • Chiropractic Care

      Plan payment percentage - 50%
      Calendar year maximum benefit per person - $600

    • Home Health Care

      Limited to 40 visits per calendar year with a "visit" defined as up to four continuous hours of care. Must be pre-approved. Please see SPD for other limitations on this benefit.

    • Hearing Care

      Maximum benefit payable per ear for hearing exams, tests and hearing aid devices, every 5 years (60 months) for adults and every two years (24 months) for children - 80% up to $1,250 (no deductible)

    • Hospice Care

      Covered for a 180-day treatment period. Must be pre-approved.