ilwu-pma coastwise indemnity plan · the welfare plan’s normal eligibility require-ments for...

Hospital • Medical • SurgicalBenefits

An ILWU-PMA Welfare PlanSelf-Funded Program

Supplemental Summary Plan Description

ILWU-PMA COASTWISEINDEMNITY

PLAN

34607_Coastwise 2/12/04 9:46 AM

34607_Coastwise 2/12/04 9:46 AM

Hospital • Medical • SurgicalBenefits

An ILWU-PMA Welfare PlanSelf-Funded Program

Supplemental Summary Plan Description

ILWU-PMA COASTWISEINDEMNITY

PLAN

34607_Coastwise 2/12/04 9:46 AM Page 1

Coastwise Indemnity Plan Hospital-Medical-Surgical BenefitsThis is a description of benefits provided underthe ILWU-PMA Welfare Plan Self FundedPrograms Coastwise Indemnity Plan. TheCoastwise Indemnity Plan is effective July 1,2000 and replaces the former “Choice Port Plan”and “Non-Choice Port Plan.” The CoastwiseIndemnity Plan provides all benefits providedunder either or both of the predecessor plans asof June 30, 2000. No ILWU-PMA indemnity planbenefits are reduced or eliminated on account ofimplementation of the Coastwise IndemnityPlan. The Plan is administered by the ILWU-PMA Benefit Plans office. Claims are paid by aninsurance company under an administrativeservices only (ASO) agreement with theTrustees of the ILWU-PMA Welfare Plan. Theclaims office is called the ILWU-PMA CoastwiseClaims Office. The information in this booklet issubject to, and does not change the provisionsof the ASO agreement, the provisions of theILWU-PMA Welfare Plan Agreement, or the pro-visions of the Summary Plan Description of theWelfare Plan.

Each participant of the ILWU-PMA Welfare Planhas been provided with a Summary PlanDescription, as required by the EmployeeRetirement Income Security Act (ERISA). TheSummary Plan Description describes theWelfare Plan, its eligibility requirements andbenefits. It also informs participants aboutSupplemental Summary Plan Descriptions likethis booklet, which describe individual benefitprograms. The Supplemental Summary PlanDescriptions are supplied to Locals and are

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A Supplemental Summary PlanDescription of

ILWU-PMA Welfare PlanSelf Funded Programs


available from the ILWU-PMA Benefit PlansOffice on request.

ILWU-PMA Benefit Plans1188 Franklin Street – Suite 300

San Francisco, CA 94109(415) 673-8500

Union Trustees Employer TrusteesRobert M. McEllrath Ronald J. ForestRay Ortiz, Jr. Robert L. StephensJoseph Wenzl Michael Wechsler

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TABLE OF CONTENTS

Section 1: Coastwise Indemnity PlanEligibility........................................7

Eligibility .......................................................9Employees and Pensioners......................9Qualified Dependents ..............................9

Dual Choice................................................10Election of Coverage ..................................11Loss of Eligibility.........................................12Self Payment COBRA Continuation

Coverage ................................................13

Section 2: Important Features of the Plan ..................................15

Usual, Customary and Reasonable Charges (UCR).......................................16

Service Area...............................................16Plan Year ....................................................16Providers of Service ...................................16Preferred Provider Organization (PPO)......18Coordination of Benefits .............................19Assignment of Benefits ..............................19Subrogation/Reimbursement–

Third-Party Liability.................................19Voluntary Hospital Utilization Review.........20Voluntary Case Management.....................20In PPO Area Emergency Treatment ...........21Out of PPO Area Urgent or

Emergency Treatment ............................21Special Rights Upon Childbirth ..................22Special Rights Concerning

Mastectomy Coverage............................22

Section 3: Basic Hospital-Medical-Surgical Benefits forNon-Medicare Eligibles ..............23

Maintenance of Benefits.............................24Basic Benefits – Schedule of Allowances ..24

Hospital Benefits ....................................25Newborn Nursery Care ..........................25Skilled Nursing Facility ...........................25Hospice Care .........................................26Ambulance Benefit .................................26Medical-Surgical Benefits ......................26

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Chiropractic Treatment ...........................27Cosmetic Surgery After Mastectomy .....27Outpatient Diagnostic X-Ray and

Laboratory Benefits............................28Well Baby Care ......................................28Routine Physical Examination for

Adults .................................................28Routine Physical Examination for

Children..............................................28Mammograms ........................................29Pap Smears ...........................................29Prostate Specific Antigen (PSA) Test ...29Physical Therapy ....................................29Occupational Therapy ............................29Speech Therapy .....................................30Mental Health Benefits - Inpatient..........30Mental Health Benefits - Outpatient.......30Maternity ................................................30

Basic Benefits Exclusions ..........................31How to Claim Basic Hospital-Medical-

Surgical Benefits ....................................31

Section 4: Major Medical Benefits .............33Deductible...................................................34Stop Loss Provision....................................35Lifetime Maximum ......................................35Covered Major Medical Expenses..............35Major Medical Exclusions and Limitations .37How to Claim Major Medical Benefits ........38

Section 5: Supplemental Hospital-Medical-Surgical Benefits for Medicare Eligibles ................39

Medicare Enrollment ..................................40Covered Services .......................................41Supplemental Benefit Amounts..................41

Hospital Benefits ....................................42Medical and Surgical Benefits ...............42Mental Health Benefits...........................43

Supplemental Plan Exclusions...................43How to Claim Medicare Benefits ................43How To Claim Supplemental Plan

Benefits ..................................................44

Section 6: Additional Medical Benefits ......47Injectables Benefit ......................................48

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Alcohol and Drug Detoxification and Outpatient Care Benefit..........................48

Kidney Dialysis Benefit...............................49Diabetic Durable Equipment Benefit ..........50Subsequent Artificial Limbs and Eyes

Benefit ....................................................50Ophthalmology Benefit ...............................51Supplementary Accident Benefit ................52How to Claim Additional Medical Benefits .52How to File Claims for Subsequent

Artificial Limbs and Eyes Benefit............53

Section 7: General Exclusions andClaims Review Procedures........55

General Exclusions ....................................56Claims Review Procedures ........................56

Claim Denial...........................................56Request for Claim Review......................58Decision on Review................................58Request for Arbitration ...........................58Decision by Coast Arbitrator ..................59Judicial Review.......................................59

Other ILWU-PMA Welfare Plan Programs...60

Index ..............................................................61

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Area Welfare Directors Phone Numbers

Southern California (866) 833-5144Northern California (877) 885-2793Oregon (866) 226-0013Washington (877) 938-6720

IRS Employer IdentificationNo. 94-6068578

Plan No. 501


SECTION 1

COASTWISE INDEMNITY PLAN ELIGIBILITY

Eligibility

Dual Choice

Election of Coverage

Loss of Eligibility

COBRA Continuation Coverage

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COASTWISE INDEMNITYPLAN ELIGIBILITY

This section explains how Coastwise IndemnityPlan eligibility is established and may be lost,and how COBRA continuation coverage may bepurchased.

EligibilityThe ILWU-PMA Welfare Plan Self FundedCoastwise Indemnity Plan provides Hospital-Medical-Surgical benefits to eligible ILWU-PMAWelfare Plan non-Medicare and Medicare eligi-ble participants and their dependents who haveelected or who are assigned CoastwiseIndemnity Plan coverage under provisions of theWelfare Agreement. The following eligibleWelfare Plan participants and their dependentsmay be covered by this Plan:

Employees and Pensioners, Including:

● Active Longshoremen, Ship Clerks, WalkingBosses/Foremen, and Watchmen membersof Locals 26 and 75.

● Most Pensioners under the ILWU-PMAPension Plan or the ILWU-PMA WatchmenPension Plan.

● Certain Social Security Retirees.

● Certain Active and Retired Employees of theILWU, ILWU-PMA Benefit Plans and ILWULocals.

Qualified Dependents, Including:

● Spouse.

● Unmarried dependent children to age 19.

● Unmarried dependent children age 19 to 23who are full-time students (student certifica-tion is required).

● Unmarried dependent children age 19 or overwho are physically or mentally incapacitated,who were incapacitated when they attainedage 19 (or age 23 in the case of full-time

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students), and who are incapable of self-sus-taining employment (medical certification isrequired).

● Surviving spouse and surviving dependentchildren of eligible active and retired em-ployees.

Dual ChoiceWhere a qualified HMO is available, a choice ofHospital-Medical-Surgical coverage is offered toemployees, retirees and survivors who are eligi-ble under the Welfare Plan. The choice isbetween an HMO (group practice) plan availablein the area of the port, and the CoastwiseIndemnity Plan. This choice is offered when anemployee, retiree or survivor is first eligible for adual choice, and again each year during themonth of May for coverage effective the follow-ing July 1. In addition, employees, retirees andsurvivors are allowed to change their choice ofcoverage one other time during a Plan Year,(July 1 - June 30). Information about the choiceis made available by the Welfare Plan Office.Currently, the choice between an HMO and theCoastwise Indemnity Plan is available to em-ployees registered in and retirees and survivorsliving in the ports listed on pages 11 and 12.

New registrants and their dependents in portswith HMO coverage will, on the first of the monthfollowing registration (with no requirement for400 hours of work for initial eligibility for cover-age), be covered by the HMO programs for thefirst eighteen (18) months of registration. After

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Address changes and changes in familystatus which might affect Welfare Plan eligi-bility such as marriage, divorce, birth ordeath of a dependent must be reportedimmediately in writing to the ILWU-PMABenefit Plans Office. Record Change formsfor this purpose are available at the Localsor on request from the Benefit Plans Office.


18 months of registration the member will havea choice of HMO or Coastwise Indemnity Plancoverage and normal welfare plan eligibilityrequirements shall apply.

The Trustees of the Welfare Plan may provide onan “exception basis” that a person eligible forHMO coverage under this provision may be pro-vided limited coverage under the CoastwiseIndemnity Plan specific to any serious healthcondition for which they are receiving treatmentwhen Welfare Plan coverage begins.

New registrants and their dependents in portswithout HMO coverage will, on the first of themonth following registration (with no require-ment for 400 hours of work for initial eligibility forcoverage), be covered by the CoastwiseIndemnity Plan for the first eighteen (18) monthsof registration and shall thereafter be subject tothe Welfare Plan’s normal eligibility require-ments for continuation of coverage under theCoastwise Indemnity Plan.

In ports and areas where no qualified HMO isavailable, employees, retirees and survivors areassigned coverage under the CoastwiseIndemnity Plan.

Election of CoverageActive Employees and Their Dependents:

Eligible active employees, and their dependents,who are assigned to the following ports mayelect Coastwise Indemnity Plan coverage.Currently, ILWU Locals that are offered a dualchoice include:

● California Locals:Los Angeles Area.....................13, 26, 63, 94San Diego Area..........................................29San Francisco Bay Area ..........10, 34, 75, 91Sacramento Area ...........................18, 34, 91Stockton Area.................................34, 54, 91

● Oregon Locals:Portland/Columbia River Area......4, 8, 40, 92

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● Washington Locals:Seattle/Tacoma Areas..............19, 23, 52, 98Everett/Olympia Areas .........................32, 47

Retired Employees and Survivors:

When a retiree or survivor moves to any one ofthe dual choice port areas listed above, he orshe is offered a choice of plans. Retired employ-ees and survivors who report a change ofaddress are transferred, if necessary, to a planavailable where they live. The transfer willcoincide as nearly as possible with the move.

Loss of EligibilityEligibility for all ILWU-PMA Welfare Plan bene-fits, including Coastwise Indemnity Plan bene-fits, ends upon:

● Loss of eligibility under the terms and condi-tions of the ILWU-PMA Welfare Plan.

● Loss of qualified dependent status asdefined by the ILWU-PMA Welfare Plan.

Eligibility for Coastwise Indemnity Plan Hospital-Medical-Surgical benefits ends for retiredemployees or survivors and their dependentswho are required to enroll for Medicare but whofail to maintain Medicare Part B enrollment.

Eligibility for Coastwise Indemnity Plan cover-age also ends upon transfer to an HMO plan –see page 10 “Dual Choice.”

For further information about dependent qualifi-cations and how eligibility under the ILWU-PMAWelfare Plan is established and may be lost,please refer to the ILWU-PMA Welfare PlanSummary Plan Description.

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If you are newly enrolled in the CoastwiseIndemnity Plan, or if you are visiting a newdoctor or medical facility, take this bookletwith you on your first visit. The booklet willhelp explain your benefits and claim proce-dures to a new provider.


Upon loss of eligibility for Coastwise IndemnityPlan benefits, an insurance company providesfor conversion from group coverage to an indi-vidual plan. Conditions and benefits of the indi-vidual plan are different from group coverage.

Information about the individual plan and its costis furnished upon loss of eligibility, or may berequested from the Coastwise Claims Office.

■ COBRA Continuation CoveragePersons who lose ILWU-PMA Welfare Plan eligi-bility as described above will be informed by theWelfare Plan office if they are entitled to COBRAcontinuation coverage.

COBRA is the nickname of a federal law, theConsolidated Omnibus Budget ReconciliationAct. COBRA requires that the Trustees of theILWU-PMA Welfare Plan offer Welfare Plan par-ticipants and family members the opportunity fora temporary extension of certain Welfare Planbenefits, called “continuation coverage”, whencoverage under the Plan would ordinarily end.

COBRA continuation coverage is self-paid cov-erage, that is, the eligible person must pay for it.The cost is the same as the cost to the Plan ofgroup coverage, plus a 2% administration fee.

COBRA continuation coverage may be pur-chased for a limited time only, generally either18 months or 36 months, depending on the rea-son for loss of group coverage. Examples: ADependent child who loses group coveragebecause he or she exceeds the maximum agefor dependent eligibility may purchase continua-tion coverage for up to 36 months, as may aspouse who loses group coverage because ofdivorce. An employee who loses group cover-age because of insufficient hours worked orcredited may purchase continuation coveragefor up to 18 months. Detailed information will beprovided to persons who become entitled to pur-chase COBRA continuation coverage. Abrochure about COBRA has also been fur-nished to Locals and is available from theWelfare Plan office on request.

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SECTION 2

IMPORTANT FEATURES OF THE PLAN

This section contains information of interest to all Coastwise Indemnity Plan eligibles,including a description of important Plan

features and definitions of terms which willbe used elsewhere in the booklet.

UCR (Usual, Customary and Reasonablecharges)

Service Area

Plan Year

Providers of Service

Preferred Provider Organization (PPO)

Coordination of Benefits

Assignment of Benefits

Subrogation – Third Party Liability

Voluntary Hospital Utilization Review

Voluntary Case Management

In PPO Area Emergency Treatment

Out of PPO Area Urgent or EmergencyTreatment

Special Rights Upon Childbirth

Special Rights Concerning MastectomyCoverage

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IMPORTANT FEATURES OF THE PLAN

Usual, Customary and ReasonableCharges (UCR)UCR charges, as used in this booklet, refers tocharges which are reasonable and in line withfees customarily charged for the treatment orservice rendered by providers of care in thesame area.

Service AreaAll eligibles are covered for services providedanywhere in the world. Coverage outside theUnited States will be provided at 100% of UCRin the country where the expenses are incurred.To the extent that UCR cannot be determinedspecific to the area in which the claims areincurred, the Plan will use every effort to find areasonable substitute. Claims incurred outsidethe United States are subject to the same stan-dards of medical necessity and medical treat-ment protocols as if they had been incurred inthe United States.

Plan YearThe Plan Year is July 1-June 30. This is thebasis for all annual benefit renewals and limita-tions.

Providers of ServiceThe Coastwise Indemnity Plan covers servicesprovided by any licensed doctor, or at anylicensed hospital or Medicare approved skillednursing facility. See definitions below.

The term “Doctor” means a licensed practitionerof the healing arts acting within the scope of hisor her license as a: Medical Doctor (MD),Osteopath (DO), Podiatrist (DPM), Chiropractor(DC), Registered Physical Therapist (RPT),Psychologist (Ph.D. or Psy.D.), Licensed ClinicalSocial Worker (LCSW), Marriage, Family andChild Counselor (MFCC), Acupuncturist,Marriage and Family Therapist (MFT), CertifiedMental Health Counselor (CMHC), Board

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Certified Social Worker (BCSW), DentalSurgeon (DDS), Registered Nurse Practitioner(RNP), or Physician Assistant (PA).

“Doctor” will also include:

1. A Nurse Midwife who is certified by theAmerican College of Nurse Midwives and islicensed to practice by the state in whichservices are rendered.

2. An Occupational Therapist, Speech Pathol-ogist or Audiologist when the covered personis referred to such a practitioner by a MedicalDoctor (MD) or Osteopath (DO).

3. A Registered Nurse with a Masters Degree inpsychiatric mental health nursing and twoyears of supervised experience in psychiatricmental health nursing, but only upon referralby a Medical Doctor (MD) or Osteopath (DO).

The term “Hospital” means a licensed acutecare facility which operates primarily for thediagnostic and therapeutic treatment of sick orinjured persons as resident inpatients. In noevent will the term “Hospital” include any institu-tion which is primarily a clinic, nursing home,convalescent home, skilled nursing facility orsimilar establishment. Confinement in a specialunit of a Hospital used primarily as a rest home,convalescent home or skilled nursing facility willnot be considered to be confinement in aHospital.

The term “Hospital” will also include:

1. A licensed Medicare-approved ambulatorysurgical facility and a licensed non-Medicareapproved ambulatory surgical facility if it isoperated primarily for the purpose of per-forming surgical procedures on an outpatientbasis, has a doctor and registered nurse inattendance when a patient is present, and isnot an office maintained by a physician for thegeneral practice of medicine or dentistry.

2. A psychiatric health hospital licensed by thestate in which it operates, when inpatient

17


treatment is provided there for psychiatric ormental conditions.

3. A medical institution licensed by the state inwhich it operates to provide treatment of alco-holism and drug addiction on an inpatientbasis and which has the capacity to providemedical and detoxification treatment.Residential treatment facilities that do nothave the capacity to provide medical treat-ment are not covered as hospitals.

Preferred Provider Organization (PPO)(Non-Medicare Eligibles Only)The Welfare Plan has entered into agreementswith Preferred Provider Organizations (PPOs) toprovide medical care to plan members at specialrates. These preferred providers include hospi-tals, doctors, x-ray, laboratory and other facili-ties. While the contracts with preferredproviders contain special reduced rates, they donot allow discrimination with regard to admis-sions or service; the quality of care is the samefor all patients. The PPO hospitals, doctors andfacilities are among those already used mostfrequently by Welfare Plan participants. ThePreferred Provider Organizations are Great-West Healthcare (formerly One Health Plan) inCalifornia, First Choice Health Network inWashington; and Managed HealthCareNorthwest in Oregon and VancouverWashington. In addition, a panel of mentalhealth service providers is available in Californiathrough Magellan Behavioral Health. You arefree to use any hospital or doctor of your choicebut the Major Medical plan will pay a higher ben-efit for Preferred Providers.

PPO directories listing the names and address-es of preferred providers are available from theLocals. If you have any questions about whethera provider is a preferred provider, you may callthe Preferred Provider Organizations directly atthe following numbers:

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Coastwise Claims Office 1-800-955-7376(Great-West Healthcare, 1-415-543-0114formerly One Health Plan)(Califo a)

Magellan(Califo

First Cho(Wash

ManagedNorthw(Oreg

Wa

CoordiCoordinaIndemnitered by mplan beabined beexceed a

AssignUnder pPlan, Weassignmother peattempt tprovidesage undeassignmcies is ebenefits other proMedicaidprovidedconvenieimply anPlan bebenefits.

SubrogThird-PThe Welor illnessonly on t


rni

Behavioral Health 1-800-424-5945rnia – Mental Health)

ice Health Network 1-800-231-6935ington & Oregon) 1-206-292-8255

HealthCare 1-800-648-6356est

on & Southern 1-503-shington)

nation of Benefitstion of Benefits applies to Cy Plan benefits when a patie

ore than one group health plrs a share of expenses. The tnefit payments of the two planctual UCR charges.

ment of Benefitsrovisions of the ILWU-PMAlfare Plan benefits are not s

ent by a participant, beneficiarson except the Trustees, o do so shall be void. Howeve that in the case of persons wr a State Medicaid program, a

ent of benefits to State Medicnforceable against the Plan

are paid directly to a doctor, hvider of care (other than to agency), such direct paym at the discretion of the Trustnce to Plan participants an enforceable assignment onefits or the right to rece

ation/Reimbursement–arty Liability

fare Plan will pay benefits for for which a third party may

he condition that the covered p

19

413-5800

oastwisent is cov-an. Eachotal com-s will not

Welfareubject tory or anyand anyr, ERISAith cover-utomatic

aid agen-. Whereospital or a Stateents areees as ad do notf Welfareive such

an injury be liableerson, or

the legal representative of the covered person,completes an “Agreement to ReimburseBenefits” form. This is an agreement to reim-burse the Trustees of the ILWU-PMA WelfarePlan for any Welfare Plan benefits paid onaccount of an injury or illness, to the extent ben-efits or other compensation are received for thesame injury or illness under Workers’Compensation laws or from any third party.

Voluntary Hospital Utilization Review(Non-Medicare Eligibles Only)The Plan contains a voluntary hospital utilizationreview program administered by BCE Emergis.Hospital utilization review is intended to preventunnecessary expenses due to hospital confine-ments which: 1) are not medically necessary, 2)are for a longer period of time than necessary, or3) are for care which could be given on an out-patient basis. The utilization review programmay provide pre-admission certification, concur-rent review and discharge planning. Pre-admis-sion certification is performed for scheduledhospital admissions, prior to admission.Concurrent review is performed for both sched-uled and non-scheduled admissions during con-finement. Discharge planning may be providedto help arrange for discharge from the hospitalas early as possible without jeopardizing patientcare. This program is voluntary and not manda-tory. To request voluntary hospitalization review,telephone 1-(800)-326-7136.

Voluntary Case ManagementThe Case Management program, administeredby BCE Emergis, can provide help and supportfor patients experiencing serious or long term ill-ness. Case Management health care profes-sionals will work with the patient, family and doc-tor in arranging for treatment alternatives tolengthy hospitalizations. In certain cases, CaseManagement may get approval for benefits notusually covered by the Coastwise IndemnityPlan, such as home health care, and rehabilita-tion facility care. Case Management is a volun-tary program and does not dictate the care you

20


receive. These important decisions stay withyou and your doctor.

Patients who qualify may be identified andreferred to Case Management by the CoastwiseClaims Office or through the voluntary hospitalutilization review process; or you may call BCEEmergis Case Management directly at 1-(800)-326-7136.

In PPO Area Emergency TreatmentIf an eligible plan participant assigned to a PPOarea needs emergency medical treatment,including ambulance service, the person need-ing the emergency treatment should go immedi-ately to the nearest hospital emergency medicalfacility. The plan will reimburse the cost of suchemergency treatment at 100% of PPO negotiat-ed rates if the hospital facility, ambulance serv-ice, and/or emergency room physician is a PPOprovider. If the hospital emergency facility,ambulance service or physician is not a PPOprovider the plan will reimburse the cost ofemergency treatment at 100% of UCR. If con-tinued treatment or admission is needed, theparticipant may be required to transfer to a PPOhospital as soon as the attending physiciandetermines it is medically safe and reasonableto be transported. If the participant elects tocontinue to receive treatment at the Non-PPOhospital after the emergency period, the Planwill pay basic benefits plus major medical (80%of UCR) for the additional treatment.

A “Medical Emergency” is defined as: the sud-den onset of a medical condition that the patientbelieves requires immediate treatment becauseit is either (1) life threatening, or (2) would causea serious dysfunction or impairment of a bodyorgan or part if not immediately treated.

Out of PPO Area Emergency orUrgent Treatment If an eligible plan participant assigned to a PPOarea receives emergency or urgent medicaltreatment while outside of that PPO area, theplan will reimburse the cost of such emergency

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or urgent treatment, including ambulance serv-ice, at 100% of UCR. If continued treatment isneeded, the participant may be required totransfer back to a PPO area as soon as theattending physician determines it is medicallysafe and reasonable to be transported. If theparticipant elects to continue to receive treat-ment outside the PPO area after the urgent oremergency period, the Plan will pay basic bene-fits plus major medical (80% of UCR) for theadditional treatment.

A “Medical Emergency” or Urgent Treatment isdefined as: the sudden onset of a medical con-dition that the patient believes requires immedi-ate treatment because it is either (1) life threat-ening, or (2) would cause a serious dysfunctionor impairment of a body organ or part if notimmediately treated, or (3) a condition for whichimmediate treatment would be obtained if themedical condition occurred within a PPO area.

Special Rights Upon ChildbirthUnder federal law, group health plans may notrestrict benefits for any hospital stay in connec-tion with childbirth for the mother or newbornchild to less than 48 hours following a vaginaldelivery, or less than 96 hours following aCesarean delivery. However, the attendingphysician may discharge the mother or her new-born at any time after consultation with themother.

Special Rights ConcerningMastectomy CoverageUnder federal law, group health plans that pro-vide coverage for mastectomies (the CoastwiseIndemnity Plan does) are also required to pro-vide coverage for reconstructive surgery andprostheses following mastectomies. This cover-age will be provided in consultation with thepatient and the patient’s attending physician andis subject to the same annual deductible and co-payment provisions otherwise applicable underthe Plan.

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SECTION 3

BASIC HOSPITAL-MEDICAL-SURGICAL BENEFITS FOR NON-MEDICARE

ELIGIBLES

Maintenance of Benefits

Basic Benefits – Schedule of Allowances

Basic Benefits Exclusions

How to Claim Hospital-Medical-SurgicalBenefits

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BASIC HOSPITAL-MEDICAL-SURGICAL BENEFITS

FOR NON-MEDICARE ELIGIBLESThis section describes Hospital-Medical-Surgicalbenefits for Coastwise Indemnity Plan memberswho are not eligible for Medicare, and for activemembers who are eligible for Medicare with theWelfare Plan as their primary coverage. If youare a Medicare-eligible pensioner or theMedicare-eligible dependent of a pensioner,please go to the section called “SupplementalHospital-Medical-Surgical Benefits for MedicareEligibles” beginning on page 39. See also “MajorMedical Benefits” on page 34 and “AdditionalMedical Benefits” on page 48.

■ Maintenance of BenefitsThe Trustees monitor the Coastwise IndemnityPlan to determine whether out-of-pocket coststo beneficiaries have increased. If so, periodicadjustments in the Basic Benefits Schedule ofAllowances will be made.

■ Basic Benefits – Schedule of Allowances

The Plan pays Basic Hospital, Medical andSurgical benefits at 100% of the scheduledamounts for covered services according to theSchedule of Allowances effective on the dateclaims are incurred. The Schedule ofAllowances shown in this booklet is effectiveOctober 2003 and will be updated every Apriland October. For the latest Schedule ofAllowances, contact your Local or the BenefitPlans office, or call the Claims Office at (415)543-0114 or (800) 955-7376.

In addition to the Basic Benefits provided underthe Schedule of Allowances, the CoastwiseIndemnity Plan provides Major Medical benefitsafter maximum Basic Benefits have been paidand after any applicable deductible has beensatisfied. Major Medical benefits are describedon page 34.

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Basic Benefits cover only the specific type ofexpenses listed below if they are medically nec-essary and are ordered by a doctor for treatmentof an illness or injury.

Hospital BenefitsSee the definition of “Hospital” on page 17.

Room and Board: Up to $504.56 room and boardper day, for up to 365 days per confinement.

Hospital Extras:PPO: 100% of PPO chargesNon-PPO: Up to $6,307.83 with any balance

at 80% of UCR under Major Medical.No PPO Access: 100% of UCR

per confinement for necessary services andsupplies charged by the hospital other thanroom and board. The Hospital Extras benefitcovers inpatient hospital charges for suppliesand services other than room and board, outpa-tient hospital charges for surgery or emergencycare, and surgery charges from approved ambu-latory surgi-centers.

Renewal of Hospital Benefits: Hospital benefits,including in-hospital doctor visits, surgery, assis-tant surgeon and anesthesiologist benefits,renew for each separate confinement when dueto entirely unrelated causes. When successivehospital confinements are due to the same orrelated cause, hospital benefits renew for activeemployees on the earlier of return to work(including availability for work) or three monthsfollowing discharge from the hospital; for retiredemployees, survivors and dependents, hospitalbenefits renew three months following dischargefrom the hospital.

Newborn Nursery CarePPO: 100% of PPO chargesNon-PPO: 80% of UCR chargesNo PPO Access: 100% of UCR charges

Skilled Nursing FacilityUp to 100 days per Plan Year (July 1 – June 30)for extended care in Medicare approved facili-ties; confinement must begin within 14 days

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after a confinement of at least 3 days in an acutecare hospital.PPO: 100% of PPO semi-private room rate.Non-PPO: 80% of UCR semi-private room rate.No PPO Access: 100% of UCR semi-private

room rate.

Hospice Care100% up to UCR for all covered services up to90 days which can be extended by physician.Also, 90 days for bereavement from date ofdeath.

Ambulance BenefitUp to $466.21 hospital per confinement fortransportation to or from a hospital; included inthe “Hospital Extras” benefit. Note: Emergencyambulance service is covered under EmergencyTreatment on pages 21 and 22.

Medical-Surgical BenefitsDoctor Office Visits: $38.35 per visit.

Doctor Home Visits: $62.94 per visit.

See definition of “Doctor” on page 16.

Payment is limited to one visit per day for eacheligible person unless the visits are to differentdoctors for separate and unrelated conditions.

Doctor Hospital Visits: $38.35 per visit, limited toone visit for each day of inpatient confinement.Maximum payment per hospital confinement;$13,997.75.

Surgery: Up to a maximum of $11,524 per dis-ability. The maximum payment for any one sur-gical procedure is based on the 1964 RelativeValue Schedule (RVS), translated to andexpanded into up-to-date Current ProceduralTerminology (CPT4) codes at $57.62 for eachunit listed for the procedure. Radiation Therapyand surgical services for maternity are coveredunder the Surgical benefit.

Example: An appendectomy is listed at 40units. The maximum allowance for the sur-geon is $2,304.80 (40 units times $57.62).

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Multiple Surgical Procedures During the SameOperative Session: Full Plan benefits arepayable for the major surgical procedure, plus50% of Plan benefits for each lesser procedurewhich adds significantly to the time and com-plexity of the operation, up to the Surgery maxi-mum per disability. No benefits are payable forincidental procedures which do not add signifi-cantly to the time and complexity of an operation.

All operations for the same condition are con-sidered a single disability, subject to the surgerymaximum.

Assistant Surgeon: 20% of the Surgeryallowance based on the RVS unit allowance upto a maximum of $2,304.80 per disability.

Anesthesiologist (MD): Up to $57.62 per unitbased on the unit allowance and “AnesthesiaTime Units” of one unit per quarter hour, up to amaximum of $3,841.35 per disability.

Example: An Appendectomy has an anesthe-sia value of four units. If the anesthesia timeis 60 minutes, the maximum payment is$460.96 - four units plus four quarter-hourtime units = eight units times $57.62. If anes-thesia is administered by other than an anes-thesiologist (MD), payment is one-half of theamount calculated for the anesthesiologist.

Chiropractic Treatment$38.35 per visit, limited to 40 visits per Plan Year(July 1 – June 30) except where the WelfarePlan chiropractic consultant decides additionalvisits are medically necessary.

Cosmetic Surgery After MastectomyIf all or part of a breast is surgically removed formedically necessary reasons, the followingservices are covered:

Reconstruction of the breast on which themastectomy was performed;

Surgery and reconstruction of the otherbreast to produce a symmetrical (balanced)appearance;

27


Prostheses (artificial replacements); and,

Services for physical complications resultingfrom the mastectomy.

Outpatient Diagnostic X-Ray AndLaboratory BenefitsMaximum of $630.78 per condition each sixmonths. Benefit renews January 1 and July 1 ofeach year.

Well Baby CarePPO: Covered as any other medical condition at100% of PPO charges during the child’s firstyear.

Non-PPO: Covered as any other medical condi-tion at 80% of UCR during child’s first year.

No PPO Access: Covered as any other medicalcondition at 100% of UCR during child’s firstyear.

Thereafter, maximum of $250.00 per year (frombirthday to birthday) until the child’s thirdbirthday.

Routine Physical Examination for AdultsPPO: 100% of covered PPO charges for theexam and related lab and x-ray charges; maxi-mum of one each Plan Year.

Non-PPO: 80% of UCR for exam and relatedlab and x-ray charges; maximum of one eachPlan Year up to $400.

No PPO Access: 100% of UCR for exam andrelated lab and x-ray charges; maximum of oneeach Plan Year.

Services related to a diagnosis paid separately.

Routine Physical Examination for ChildrenPPO: 100% of PPO charges

Non-PPO: 80% of UCR

No PPO Access: 100% of UCR

Charges covered include the exam and relatedlab and x-ray charges. A routine physical exam-ination benefit is provided for eligible dependent

28


children other than infants, up to age 19, accord-ing to the following schedule: first examinationjust before entering the first grade or during thefirst year of school; second examination after thefirst year of school and before age 13; thirdexamination between ages 13 to 19.

MammogramsBenefits are payable in full for routine mammo-grams for breast cancer screening, and therelated office visit, according to AmericanCancer Society guidelines in effect at the time oftreatment. Currently these guidelines are:

Age 35 – 39: One baseline mammogram

Ages 40 and over: One mammogram everyyear

Pap SmearsOne Pap Smear and related office visit paid infull at intervals according to American CancerSociety guidelines in effect at the time of treat-ment.

Prostate Specific Antigen (PSA) TestOne PSA (or its successor) test and relatedoffice visit paid in full every year at age 50 andover (according to American Cancer Societyguidelines).

Physical TherapyPPO: 100% of PPO charges when prescribedby a Doctor.

Non-PPO: 80% of UCR when prescribed by aDoctor.

No PPO Access: 100% of UCR when prescribedby a Doctor.

Occupational TherapyPPO: 100% of covered PPO charges whenreferred by a Doctor to a licensed PPO occupa-tional therapist.

Non-PPO: 80% of covered UCR charges whenreferred by a Doctor to a licensed occupationaltherapist.

No PPO Access: 100% of UCR charges when

29


referred by a Doctor to a licensed occupationaltherapist.

Speech TherapyPPO: 100% of PPO charges when referred by aDoctor to a licensed PPO speech pathologist oraudiologist.

Non-PPO: 80% of UCR charges when referredby a Doctor to a licensed speech pathologist oraudiologist.

No PPO Access: 100% of UCR charges whenreferred by a Doctor to a licensed speechpathologist or audiologist.

Mental Health Benefits – InpatientPPO: Paid the same as any other illness

Non-PPO: Paid the same as any other illness

No PPO Access: Paid the same as any otherillness

Mental Health Benefits – OutpatientPPO: First 20 visits per Plan Year paid the sameas any other illness, 100% of PPO charges.Next 30 visits in same Plan Year paid at $38.35per visit plus $10 under Major Medical. Maxi-mum number of visits per Plan Year is 50.

Non-PPO: First 20 visits per Plan Year paid thesame as any other illness, after basic benefits80% of UCR charges. Next 30 visits in samePlan Year paid at $38.35 per visit plus $10 underMajor Medical. Maximum number of visits perPlan Year is 50.

No PPO Access: First 20 visits per Plan Yearpaid the same as any other illness, 100% ofUCR charges. Next 30 visits in same Plan Yearpaid at $38.35 per visit plus $10 under MajorMedical. Maximum number of visits per PlanYear is 50.

MaternityExpenses for maternity are paid on the samebasis as expenses for any other medical condi-tion. This means hospitalization for normaldelivery, Cesarean delivery, and interrupted

30


pregnancy are payable according to theallowances listed under “Hospital Benefits.”Benefits for doctors’ services are paid based onthe per unit surgical allowance. This allowanceincludes prenatal care, delivery, post-deliverycare, and required urinalysis charges.Additional laboratory tests are payable underthe Outpatient Diagnostic X-ray and LaboratoryBenefits allowance described on page 28.

■ Basic Benefits ExclusionsBasic Hospital-Medical-Surgical Benefits do notcover:

● General Exclusions on page 56.

● Any type of medical expense not specificallylisted as a covered Basic Plan Benefit.

● Foot appliances and required castings.

● Medical equipment, including but not limitedto, casts, prosthetic devices such as artificiallimbs and eyes, orthopedic appliances,braces, crutches, wheelchairs, hospital beds,oxygen and the rental of equipment for itsadministration. Note: Some of these itemsare covered under Major Medical Benefits –see pages 35, 36 and 37.

● Care in a convalescent home or rest home.

● Optometrical services, including examina-tions, refractions, visual aids or orthoptics.

■ How to Claim Basic Hospital-Medical-Surgical Benefits

Claims for Hospital-Medical-Surgical benefitsdescribed above are to be filed with theCoastwise Claims Office, using a Claim Form forHospital, Medical, Surgical Benefits. Claimforms are available at the Locals, or may berequested from the Coastwise Claims Office orthe Benefit Plans Office. The claim forms arepre-printed with the group name and theCoastwise Claims Office address; no policynumber is required to identify your claim. Claims

31


should be filed within 180 days from the datecovered expenses are incurred but will beaccepted for up to three years unless a later fil-ing date is allowed by the Trustees.

The claim form Part 1 – Employee Statementmust be completed by the eligible claimant,active employee, pensioner or survivor. Part 2 –Physician Statement must be completed bythe attending doctor or other provider of service.The doctor must itemize all charges on the claimform OR attach an itemized bill. For hospitalbenefits, an itemized bill must be attached to theclaim form.

The claimant may direct the Coastwise ClaimsOffice to pay benefits directly to the provider.See assignment of benefits on page 19.

Mail claims to:

ILWU-PMA Coastwise IndemnityPlan Claims Office

814 Mission St., Suite 300San Francisco, CA 94103

32


SECTION 4

MAJOR MEDICAL BENEFITS

Deductible and Percentage Payable

Stop Loss Provision

Lifetime Maximum

Covered Major Medical Expenses

Major Medical Exclusions and Limitations

How to Claim Major Medical Benefits

33


MAJOR MEDICAL BENEFITSThis section applies to all Coastwise IndemnityPlan members, both with and without Medicare.

The Coastwise Indemnity Plan provides MajorMedical coverage in addition to Basic PlanBenefits for non-Medicare eligibles, and in addi-tion to the Supplemental Plan for Medicareeligibles.

After maximum Basic Plan Benefits orSupplemental Plan benefits have been paid andany applicable annual deductible has been sat-isfied, Major Medical benefits will reimburse thefollowing percentages of covered expenses, upto the lifetime maximum.

PPO 100% of PPO charges.

Non-PPO 80% of UCR charges.

No PPO Access 100% of UCR charges.

See Exclusions and Limitations on page 37.See page 18 for information about the PreferredProvider Organizations.

Major Medical benefits also include a Stop LossProvision, described below, which increasespayment to 100% of covered expenses after athreshold of expense has been reached.

■ DeductibleThe deductible is the amount of out-of-pocketexpenses you must pay each year before thePlan begins to pay Major Medical benefits. TheMajor Medical annual deductible amount is:

PPO None

Non-PPO $100 per person

No PPO Access: None

A new deductible must be satisfied each PlanYear (July 1 – June 30). Deductible amountsincurred during the last three months of a PlanYear will be carried over as a credit toward thedeductible in the following year. No carry-over isallowed from any year during which the

34


deductible is satisfied within the first ninemonths of the year.

A separate deductible applies to each familymember, but no more than $300 will be appliedto the covered expenses of any one family.

If two or more family members are injured in acommon accident, only one deductible will becharged to the group for expenses related tothat accident.

■ Stop Loss ProvisionDuring a Plan Year (July 1 – June 30) when afamily has incurred $5,000 of covered MajorMedical expenses, (in addition to any applicabledeductibles) additional Major Medical coveredexpenses are then payable at 100% of UCRcharges for the remainder of the Plan Year. ThisStop Loss provision does not increase the max-imum number of covered outpatient mentalhealth visits (50 per Plan Year), nor does itincrease the amounts payable for these visits.

■ Lifetime MaximumThe lifetime maximum Major Medical benefit percovered person is $2,000,000.

Restoration of Maximum: On July 1st of eachyear the maximum amount will be restored by$20,000 or the amount of Major Medical benefitsused, whichever is less. In no event will themaximum amount be increased to more than$2,000,000.

■ Covered Major Medical ExpensesExpenses for the following are covered underthe Major Medical benefit:

● Daily hospital room and board charges,beginning with the first day of confinement,are covered at the hospital’s semi-privateroom rate.

● Intensive Care Unit (ICU) charges beginningwith the first day of confinement in ICU.

● Coronary Care Unit charges beginning withthe first day of confinement.

35


● Hospitalization in isolation when ordered by aphysician.

● Emergency room charges.

● Services and supplies furnished by a hospital(hospital extras).

● Treatment by a physician or surgeon.

● Services of a registered nurse and treatmentby a licensed physiotherapist, other than onerelated by blood or marriage to the patient orone who lives in the patient’s home.

● Anesthesia and its administration.

● Dental treatment for a fractured jaw or forinjury to or replacement of sound naturalteeth within six months after an accidentincurred while covered under the Plan (cov-ered only after maximum payments under theLongshore Adult or Children’s Dental Planhave been made).

● Diagnostic radiology, radiation therapy andlaboratory examinations.

● Licensed ambulance service to and from thehospital.

● Blood and blood plasma; casts and splints.

● Braces, crutches, rental of wheelchairs orhospital beds; oxygen and the rental of equip-ment for its administration; and initial pros-thetic devices including initial (under thisplan) but not subsequent artificial limbs andeyes. See description of SubsequentArtificial Limbs and Eyes Benefit on page 50.If the rental cost of covered equipment wouldexceed the purchase price, the Plan will coverthe purchase price. Note: These items areexclusions under Basic Plan Benefits.

● Non-PPO benefits for the treatment of mentalor emotional conditions as an outpatient, visits 1 through 20 as described on page 30.

● Benefits for the treatment of mental or emo-tional conditions as an outpatient are limited

36


to $10 per visit for the 21st through 50th vis-its in a Plan Year (July 1 - June 30).

(Note: The doctor visit benefit under BasicBenefits is also payable for outpatient mentalhealth visits in addition to the $10 benefitpayable under Major Medical. See page 26for Basic Benefit.)

● Skilled Nursing Facilities – extended care inMedicare-approved facilities.

● Chiropractic Treatment – limited to 40 visitsper Plan Year (July 1 – June 30) except wherethe Welfare Plan chiropractic consultantdecides additional visits are medically neces-sary.

■ Major Medical Exclusions andLimitations

● General Exclusions on page 56 are not cov-ered under Major Medical benefits.

● Payment is made only for charges which arereasonable and in line with the fees custom-arily charged for the treatment or service ren-dered by providers of care in the same area.

● Except where specifically noted above, serv-ices that are excluded under Basic PlanBenefits or under the Supplemental Plan arealso excluded under Major Medical benefits.

● Benefits for the treatment of mental or emo-tional conditions as an outpatient are limitedto $10 per visit for visits 21 through 50 in aPlan Year (July 1 – June 30).

(Note: The doctor visit benefit under BasicBenefits is also payable for outpatient mentalhealth visits in addition to the $10 benefitpayable under Major Medical. See page 26for Basic Benefit.)

● Cosmetic surgery is not covered except if it isnecessary as the result of an accidentincurred while covered under the Plan and ifit is performed within six months of the datethe accident occurred. Cosmetic surgery to

37


correct abnormal congenital conditions of achild born while the mother is covered underthe Plan is a covered benefit.

● Treatment for alcoholism and drug addictionis not covered under the Major Medical bene-fit. Refer to Additional Medical Benefits onpage 48.

● The Prescription Drug Program co-paymentis not covered.

■ How to Claim Major MedicalBenefits

Major Medical payments are calculated at thesame time as Basic Plan Benefits andSupplemental Plan payments. Therefore, it isnot necessary to submit separate claims forMajor Medical benefits. Claims for MajorMedical Benefits are subject to the same claimprocedures as Basic Benefits.

The claimant may direct the Coastwise ClaimsOffice to pay benefits directly to the provider.See Assignment of Benefits on page 19.

38


SECTION 5

SUPPLEMENTAL HOSPITAL-MEDICAL - SURGICAL

BENEFITS FOR MEDICARE ELIGIBLES

Medicare Enrollment

Covered Services

Supplemental Benefit Amounts

Supplemental Plan Exclusions

How to Claim Medicare Benefits

How to Claim Supplemental Plan Benefits

39


SUPPLEMENTAL HOSPITAL-MEDICAL-SURGICAL BENEFITS

FOR MEDICARE ELIGIBLESThis section describes the Coastwise IndemnityPlan Supplemental Hospital, Medical, Surgicalbenefits for eligible pensioners and survivorswith Medicare. If you are not eligible forMedicare (either because of your age orbecause you live outside the United States), or ifyou are an active employee (or dependent),please go to the section called “Basic Hospital-Medical-Surgical Benefits for Non-MedicareEligibles”, beginning on page 24. See also“Major Medical Benefits” on page 34.

Eligible pensioners and survivors with Medicareshall in no way be disadvantaged due to enroll-ment in Medicare. These eligibles are entitled toany and all benefits covered under theCoastwise Indemnity Plan.

Medicare EnrollmentMedicare coverage is available to persons age65 and over, and to Social Security disabilityretirees under age 65 who have received dis-ability benefits for 24 months. Persons requiringkidney dialysis become eligible for Medicareafter a period of dialysis treatments or uponreceiving a kidney transplant.

Medicare provides hospital benefits (MedicarePart A) and medical benefits (Medicare Part B).Medicare Part B is not automatic. The eligibleperson must enroll and pay a monthly premium,which may be deducted by Social Security fromyour monthly Social Security benefits. Themonthly premium charged by Social Security forMedicare Part B benefits is reimbursed to theretiree or survivor by the Welfare Plan.

A handbook containing a complete explanationof Medicare benefits and instructions for filingMedicare claims is available in your SocialSecurity Office.

40


Covered ServicesAll Medicare-approved services are covered bythe Supplemental Plan. The Medicare hand-book available at your Social Security officedescribes Medicare-approved services in detail.

Supplemental Benefit AmountsSupplemental Coastwise Indemnity Plan ben-efits for Medicare eligibles are intended to sup-plement the benefits provided by Medicare. TheSupplemental Plan pays the deductibles andcopayments not paid by Medicare for coveredservices, and pays the difference, if any,between Medicare-allowed charges and Usual,Customary and Reasonable charges forHospital, Medical and Surgical services.

41

Coastwise Indemnity Plan hospital-medical-surgical benefits are integratedwith primary Medicare coverage.Retired members and their dependent(s)must, if eligible, enroll in Part B ofMedicare in order to maintain their eligi-bility for Coastwise Indemnity Plan hos-pital-medical-surgical benefits. Retiredmembers and/or survivors who perma-nently reside outside the United Statesand do not intend to return to obtainmedical care in the United States are notrequired to enroll in Medicare sinceMedicare benefits are not available outof the country.

Under federal law, active employees andtheir dependents who are eligible forMedicare continue until retirement to becovered primarily under the ILWU-PMAWelfare Plan. Therefore, active employ-ees are not required to enroll forMedicare even when eligible to do so.Upon retirement, such employees will berequired to enroll for Medicare Part B,and will be advised by the Welfare Planoffice as to the procedures for enrolling.


All Supplemental benefit claims for servicescovered by Medicare must be submitted firstto Medicare for payment or denial, then tothe Coastwise Claims Office for payment ofSupplemental and Major Medical benefits.The claims procedure for Medicare eligiblesis described in greater detail on page 43.

Hospital BenefitsMedicare Part A covers hospital charges, exceptfor a per benefit period deductible. TheSupplemental Plan pays this hospital deductibleplus the daily coinsurance amount not paid byMedicare for the 61st through the 90th day ofconfinement per benefit period.

Medical and Surgical BenefitsAfter an annual deductible has been satisfied,Medicare Part B pays 80% of all Medicareallowed charges. Medicare-allowed charges arethat portion of a doctor’s or other provider’scharges that Medicare determines to bereasonable.

The Supplemental Plan pays the Medicare PartB annual deductible, the 20% Medicare-allowedcharge not paid by Medicare, and the difference,if any, between the Medicare-allowed chargesand Usual, Customary and Reasonablecharges. Medicare and Supplemental Plan pay-ments will in no case exceed the actual charges.

Example:(a) Doctor’s Charge (determined to be Usual,

Customary and Reasonable) ..................$52(b) Medicare-allowed charge........................$45(c) Medicare Payment (80% of Medicare-

allowed charge) ......................................$36(d) Supplemental Plan payment ...................$16

The Supplemental Plan payment in this exampleis the difference between the Medicare paymentand the actual charge, determined to be aUsual, Customary and Reasonable charge.

If any UCR out-of-pocket expenses forMedicare-covered hospital-medical-surgicalservices remain after the Supplemental Plan

42


payment is made, such expenses are payableunder the Major Medical Benefit. In addition,out-of-pocket expenses that are not covered byMedicare will be payable under theSupplemental Plan if they are covered under theBasic, Major Medical, or Additional Benefits forNon-Medicare eligibles. Basic and MajorMedical benefits are described fully in the sec-tions beginning on page 24 and page 34.

Mental Health BenefitsMedicare eligibles have coverage under theSupplemental Plan, at 100% of UCR fees, forMedicare covered mental health services andCoastwise Indemnity Plan covered mentalhealth services as described on page 30.

■ Supplemental Plan ExclusionsSupplemental Plan Hospital-Medical-SurgicalBenefits for Medicare eligibles do not include:

● General Exclusions on page 56.

● Services not covered by Medicare, except asnoted above unless they are covered underthe Basic, Major Medical or AdditionalBenefits for non-Medicare eligibles.

■ How to Claim Medicare BenefitsMedicare eligibles must file all claims for servic-es covered by Medicare with Medicare first. TheSocial Security Medicare handbook tells how tosubmit and where to submit Medicare claims. Acurrent edition of the handbook is available atany Social Security Office.

Medicare payments can be made directly to thedoctor or other provider of service. Medicarecalls this optional payment method Assignmentof Benefits. When the assignment method isused, the doctor or provider agrees that the totalcharge for the covered service will not exceedthe charge approved by Medicare.

43


If the provider does not accept Assignment ofBenefits, then Medicare payment is made direct-ly to the eligible person.

When Medicare processes a claim, the eligibleperson receives a record of the action Medicarehas taken on the claim. This can be a record ofhospital benefits used under Medicare or anexplanation of Medicare benefits. This Medicarerecord must then be submitted to the CoastwiseClaims Office for payment of SupplementalHospital-Medical-Surgical Benefits.

■ How to Claim Supplemental PlanBenefits

Claim forms, called “Claim for SupplementalPlan Benefits”, are supplied to the Locals andavailable on request from the Coastwise ClaimsOffice or the Welfare Plan Office. To claimSupplemental benefits, the eligible person mustcomplete one of these forms. The claim formsare pre-printed with the group name and theCoastwise Claims Office address. No policynumber is required to identify your claim.

Claims for Supplemental Plan benefits are sub-ject to the same claim procedures as BasicBenefits and Major Medical Benefits. Theclaimant may direct the Coastwise Claims Officeto pay benefits directly to the provider. SeeAssignment of Benefits on page 19.

44

It is important to remember that ALL claimsfor services covered by Medicare must besubmitted first to Medicare, then to theCoastwise Claims Office. Even if Medicaredenies the claim the Coastwise ClaimsOffice needs the record of Medicare action(payment or denial) in order to calculateSupplemental benefits. If your claim isincurred outside the United States, youshould submit your claim form directly tothe Coastwise Claims Office as notedbelow.


Medicare records of payment, or denial, mustbe attached to the claim form.

Mail the completed claim form, with attach-ments, to:

ILWU-PMA Coastwise Indemnity PlanClaims Office


(800) 955-7376(415) 543-0114

45


46


SECTION 6

ADDITIONAL MEDICALBENEFITS

Injectables Benefit

Alcohol and Drug Detoxificationand Outpatient Care Benefit

Kidney Dialysis Benefit

Diabetic Durable Equipment Benefit

Subsequent Artificial Limbs and Eyes Benefit

Ophthalmology Benefit

Supplementary Accident Benefit

How to Claim Additional Medical Benefits

How to File Claims for the SubsequentArtificial Limbs and Eyes Benefit

47


ADDITIONAL MEDICAL BENEFITSThe additional medical benefits described in thissection are provided for all Coastwise IndemnityPlan eligibles, with and without Medicare. Thebenefits are the same for Non-Medicare andMedicare members. These benefits are paid infull up to Usual, Customary and Reasonable(UCR) charges as determined by the Trustees.

The Major Medical benefits deductible, lifetimemaximum and percentage payable provisionsare not applicable to the benefits described inthis section.

Injectables BenefitThis benefit pays up to 100% of PPO or 100% ofapplicable UCR charges for prescribed immu-nization materials and any therapeutic agentadministered by injection in the course of cov-ered treatment by a doctor. Chemotherapyinjectable medications administered by doctorsto patients who are not hospitalized are includ-ed. The benefit does not cover experimentaldrugs or drugs not generally accepted by themedical profession as proper treatment for thecondition being treated.

Alcohol and Drug Detoxification AndOutpatient Care Benefit(Note: These benefits are outside of and in addi-tion to ILWU-PMA Alcoholism/Drug RecoveryProgram (ADRP) benefits).

Non-Medicare Eligibles:

Hospital Care: Inpatient detoxification forremoval of the toxic substance from the systemwill be paid for, up to 100% of UCR charges,when provided in a licensed hospital or in a divi-sion of a licensed general hospital to a maxi-mum of five days per episode. Hospital roomand board charges are payable at the hospital’smost common semi-private room rate. HospitalExtras are payable up to 100% of UCR charges.

Outpatient Care: Up to 20 outpatient counselingvisits per Plan Year for alcoholism and drug

48


dependency are covered up to 100% of UCRcharges. The counseling must be provided by alicensed doctor or by a PhD psychologist,licensed psychiatric social worker, or a licensedmedical social worker upon prescription by alicensed doctor. Covered visits are limited toone per day.

Medicare Eligibles:

Medicare-covered inpatient detoxification or out-patient counseling for alcoholism and drugdependency is covered up to 100% of UCR fees.

Exclusions: Alcoholism and Drug DependencyTreatment does not cover care in a federal orstate hospital; care for a patient who, or condi-tion which, in the professional judgment of theattending doctor, would not be responsive totherapeutic management; house calls.

In addition to these benefits for Alcoholism andDrug Dependency Treatment which are coveredup to 100% of UCR charges, Medicare and Non-Medicare eligibles and their dependents arecovered for chemical dependency recovery pro-grams under the ILWU-PMA Alcoholism/DrugRecovery Program (ADRP). See the separatebrochure describing the ADRP.

Kidney Dialysis BenefitPersons under age 65 who require kidney dialy-sis because of permanent kidney failure becomeeligible for Medicare coverage after a period ofdialysis treatments or upon receiving a kidneytransplant. During the waiting period beforeMedicare coverage starts, the Kidney Dialysisbenefit pays up to 100% of UCR charges for kid-ney dialysis treatment at home or in a non-hos-pital treatment center. After Medicare eligibilityhas been established, the Coastwise IndemnityPlan pays Supplemental Hospital-Medical-Surgical Benefits for covered kidney dialysistreatment. The Plan pays the differencebetween Medicare-allowed charges and actualcharges, up to 100% of UCR charges.

Kidney dialysis patients must maintain enrollment

49


for Medicare Part B medical benefits, in order toretain eligibility for Coastwise Indemnity PlanSupplemental Benefits.

Diabetic Durable Equipment BenefitThis benefit is not provided under the CoastwiseIndemnity Plan; it is paid directly by the ILWU-PMA Benefit Plans Office.

The ILWU-PMA Welfare Plan Diabetic DurableEquipment Benefit covers a Blood SugarMonitor, when prescribed by a physician asmedically necessary to monitor a permanentcondition. The benefit pays up to 100% of UCRcharges.

The following limitations and exclusions apply tothe Diabetic Durable Equipment Benefit:

● Only one Blood Sugar Monitor is provided perfamily.

● The benefit is not provided for injectiondevices or any other kind of equipmentexcept a Blood Sugar Monitor.

● Diabetic supplies (needles, insulin, syringes,test tape and tablets) are not covered underthis benefit. These items are covered, how-ever, under the ILWU-PMA Welfare PlanPrescription Drug Program.

● Medicare eligibles are not covered under thisbenefit unless a blood sugar monitor is med-ically necessary but not covered by Medicare.Medicare eligibles must first file a claim withMedicare and then include a copy of Medi-care’s denial when sending a claim form tothe Benefit Plans office.

Subsequent Artificial Limbs and Eyes BenefitThe ILWU-PMA Welfare Plan SubsequentArtificial Limbs and Eyes Benefit provides formedically necessary replacements of artificiallimbs and eyes.

“Medically necessary” means that a subsequentartificial limb or eye is furnished based upon a

50


physician’s certification that it is required (1) dueto loss or irreparable damage or wear to theexisting device or (2) due to a change in thepatient’s condition.

All persons with ILWU-PMA Welfare Plan eligi-bility are eligible for the Subsequent ArtificialLimbs and Eyes Benefit. This includesCoastwise Indemnity Plan members as well asmembers covered under an HMO sponsored bythe Welfare Plan.

The Plan pays 100% of Usual, Customary andReasonable charges for medically necessarysubsequent artificial limbs and eyes.

Coverage is limited to standard equipment thatis necessary and reasonable for treatment of thepatient’s illness or injury. Deluxe equipment iscovered only up to the cost of such standardequipment.

The Plan does not pay for services coveredunder Workers’ Compensation or similar laws orservices for which the patient is entitled to reim-bursement under a third party settlement.

A Subsequent Artificial Limb or Eye Claim Formmust be completed by the eligible member andmailed to the Coastwise Claims Office. TheClaim Form includes an Employee Statement, aPhysician’s Statement that must be completedby the attending physician, and a Dispenser’sStatement that must be completed by the pros-thesis vendor.

Ophthalmology Benefit (Routine Non-VSP Panel Exam)When a routine eye examination causes thecovered person to incur expenses for an exami-nation from a non-VSP panel ophthalmologistinstead of a VSP panel member, the Plan willpay the expense incurred while this coverage isin force as to such person less VSP’s paymentand less a $5.00 deductible. Routine eye exam-inations are covered not more often than once ina 12 consecutive calendar month period, irre-spective of whether the covered person sees a

51


non-VSP panel ophthalmologist or a VSP paneldoctor.

■ Supplementary Accident BenefitThis benefit is payable only in cases of acciden-tal injury. Expenses must be incurred within 90days after the accident. Up to $300 is payablefor the following, when not otherwise paid underthe Coastwise Indemnity Plan: necessary hos-pital expenses; services of doctors; services of alicensed nurse (other than one who normallylives in the patient’s home); braces, crutches,wheelchair rental; repair or replacement ofsound natural teeth if claimant is not otherwisereimbursed under the Welfare Plan.

How to Claim Additional MedicalBenefits● Claims for Injectables, Alcoholism and Drug

Dependency Treatment, Kidney Dialysis,Ophthalmology and Supplementary Accidentbenefits are filed with the Coastwise ClaimsOffice:

ILWU-PMA Coastwise Indemnity PlanClaims Office


(800) 955-7376(415) 543-0104

● To file a claim for Injectables, Alcoholism andDrug Dependency Treatment, or KidneyDialysis benefits, claimants who do not haveMedicare eligibility should use the ClaimForm for Hospital, Medical, Surgical Benefits.See page 31 for additional information onhow to file this claim form. Claimants withMedicare eligibility should use a Claim Formfor Supplemental Plan Benefits. See page 44for additional instructions.

● Claims for Diabetic Durable Equipment bene-fits are filed directly with the ILWU-PMABenefit Plans Office:

52


ILWU-PMA Benefit Plans1188 Franklin Street – Suite 300

San Francisco, CA 94109(415) 673-8500

● Claim Diabetic Durable Equipment benefitson a Diabetic Durable Equipment ClaimForm, which must be completed by the eligi-ble claimant, the prescribing doctor, and theDiabetic Durable Equipment dispenser (deal-er), and submitted with proof of purchase.Medicare eligibles must include the Medicaredenial of benefits with the claim form.

How to File Claims for theSubsequent Artificial Limbs and Eyes BenefitYou may file a claim for the Subsequent ArtificialLimb or Eye Benefit on a Subsequent ArtificialLimb or Eye Claim Form which must be com-pleted by the eligible member and mailed to theCoastwise Claims Office. The claim formincludes an Employee Statement, a Physician’sStatement that must be completed by theattending physician, and a Dispenser’sStatement that must be completed by the pros-thesis vendor.

53


54


SECTION 7

GENERAL EXCLUSIONSAND CLAIMS REVIEW

PROCEDURES

General Exclusions

Claims Review Procedures

55


This Section contains a list of general exclusionsunder the Coastwise Indemnity Plan andexplains how to obtain a review when a claim isdenied or partially denied.

■ General ExclusionsThe following general exclusions are in additionto limitations and exclusions listed elsewhere inthis booklet for Basic, Major Medical, MedicareSupplemental and Additional Benefits.

● Services which are not medically necessaryto treat an illness or injury, or which are cus-tomarily furnished without charge.

● Services performed in or outside the UnitedStates which are experimental in nature or donot meet established treatment protocols inthe United States.

● Services performed on or to the teeth exceptas specifically allowed under Major Medical.

● Services for conditions covered by state orfederal laws, workers’ compensation oremployer liability or similar laws.

● Services provided without cost by any federalor state government agency, county or municipality.

● Services for conditions caused by war or actof war.

● Benefits provided under other ILWU-PMAWelfare Plan programs.

■ Claims Review ProceduresThe procedures described below apply torequests for benefits under the CoastwiseIndemnity Plan. Please note that a mere inquiryabout whether a particular item is covered underthe Plan is not a claim for this purpose.

Claim DenialIf a claim is denied or partly denied by theCoastwise Claims Office, notice will be given tothe claimant in writing. The notice will be writtenin understandable language and will state:

56


● Specific reasons for denial of the claim;

● Specific reference to provisions of the WelfareAgreement, the Coastwise Indemnity Plan, orcontract provisions upon which the denial isbased;

● A description, if appropriate, of additionalinformation or material which might enablethe claimant to perfect the claim;

● An explanation of how, where and when theclaimant may obtain a review of the denial;

● If the denial is based on an internal rule,guideline, or protocol, the claimant has theright to request a free copy of the rule guide-line, or protocol; and

● If the denial is based on a determination thatthe treatment or services are not consideredto be standard medical treatment (e.g., areconsidered experimental), the claimant hasthe right to request a free copy of the scientif-ic or clinical judgment on which such determi-nation is based.

Notice of claim denial must be given to theclaimant within a reasonable period of time, butnot later than 30 days after the date the claim isreceived. This period may be extended an addi-tional 15 days if the Coastwise Claims Officedetermines that an extension is necessary dueto matters beyond its control and the claimant isnotified of the extension before the end of theinitial 30-day period and the date by which theCoastwise Claims Office expects to render adecision on the claim. If an extension is requiredbecause the claimant failed to submit sufficientinformation to enable the Coastwise ClaimsOffice to make a determination of the claim, thenotice of the extension will also describe theadditional information required. In such a case,the claimant will be given at least 60 days to pro-vide the additional information. The period fromthe date the claimant is notified of the additionalrequired information to the date the claimantresponds is not counted as part of the determi-nation period.

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If the Coastwise Claims Office does not respondto the claimant’s claim within the time periodsspecified above, the claimant may deem hisclaim denied for this purpose as of the expirationof the applicable time period above.

Request for Claim Review by Trustees of theILWU-PMA Welfare PlanWithin 180 days after notice that a claim hasbeen denied by the Coastwise Claims Office, orafter the claim is deemed denied as providedabove, the claimant or his/her representativemay make a written request for a review of thedenial by the Trustees of the ILWU-PMA WelfarePlan. The claimant or his/her representativemay request copies free of charge, of all docu-ments, records and other information relevant tothe claim. This includes documents relied on inmaking the benefit determination or submittedor generated in the course of the review.

A request for a review by the Trustees must besubmitted to:

ILWU-PMA Benefit Plans1188 Franklin Street, Suite 300

San Francisco, CA 94109

Decision on Review by Trustees of theILWU-PMA Welfare PlanThe Trustees of the ILWU-PMA Welfare Plan, ora committee of the Trustees, will render theirdecision on the claim within 60 days of receipt ofthe request for review.

The decision of the Trustees will be communi-cated in writing, and in understandable lan-guage. It will include specific references to theWelfare Agreement or contract provisions uponwhich the decision is based.

If the Trustees do not respond to the claimant’srequest for review within the time periods speci-fied above, the claimant may deem his claimdenied on review for this purpose as of the expi-ration of the applicable time period above.

Request for ArbitrationAfter notice that a claim has been denied by the

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Trustees on review, or after the claim is deemeddenied on review as provided above, theclaimant may request that the claim be decidedby the Coast Arbitrator. In order to obtain areview of a claim by the Coast Arbitrator, theclaimant must have obtained a prior determina-tion on the claim by the Trustees (or a deemeddenial) in accordance with the procedures out-lined above. The claimant or his/her represen-tative may request copies, free of charge, of alldocuments, records and other information rele-vant to the claim. This includes documentsrelied on in making the benefit determination orsubmitted or generated in the course of thereview by the Trustees.

A request for review by the Coast Arbitrator mustbe submitted to:

ILWU-PMA Benefit Plans1188 Franklin Street, Suite 300

San Francisco, CA 94109

Decision by Coast ArbitratorThe Coast Arbitrator will render a decision onthe claim within 30 days of receipt of the requestfor review. The decision of the Coast Arbitratorwill be communicated in writing, and in under-standable language. It will include specific ref-erences to the Welfare Agreement or contractprovisions upon which the decision is based.

Judicial ReviewA claimant has the right to file a suit in a court oflaw if a claim is denied or partly denied by theCoast Arbitrator. Plan provisions and applicablelaw require, however, that the claimant firstexhaust all of his or her appeal rights under thePlan. This means that a claimant must obtaindeterminations by the Trustees and by the CoastArbitrator before he or she may file a lawsuit fora benefit under the Plan.

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OTHER ILWU-PMA WELFARE PLAN PROGRAMS

In addition to the Coastwise Indemnity Plandescribed in this booklet, the ILWU-PMAWelfare Plan provides coverage for pre-scription drugs, vision care, dental benefits,death and dismemberment benefits, hear-ing aid benefits, benefits for temporary dis-abilities, and alcoholism/drug recovery pro-gram benefits. Eligibility requirements forthese additional benefits vary. For informa-tion about these benefits, please see theSummary Plan Description and the applica-ble Supplemental Summary PlanDescriptions. To find out if you are eligible,please contact the ILWU-PMA BenefitPlans Office or your Local.

Claims administration services are providedto the Coastwise Indemnity Plan under acontract for such services between theBoard of Trustees and the ILWU-PMACoastwise Indemnity Plan Claims Office.The Coastwise Claims Office is located at814 Mission St., Suite 300, San Francisco,California 94103. The Coastwise ClaimsOffice telephone numbers are (415) 543-0114 or (800) 955-7376.


COASTWISE INDEMNITY PLAN

INDEX

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AADDITIONAL MEDICAL BENEFITS, 48Alcohol and Drug Detoxification and Outpatient

Care Benefit, 48Ambulance Benefit, 26Assignment of Benefits, 19

BBasic Benefits – Schedule of Allowances, 24Basic Benefits Exclusions, 31BASIC HOSPITAL-MEDICAL-SURGICAL

BENEFITS FOR NON-MEDICAREELIGIBLES, 24

CCase Management, 20Chiropractic Treatment, 27Claim Denial, 56Claims for Supplemental Plan Benefits, 44Claims Review Procedures, 56COBRA Continuation Coverage, 13Coordination of Benefits, 19Cosmetic Surgery After Mastectomy, 27Covered Major Medical Expenses, 35Covered Services, 41

DDecision on Review, 58Deductible, 34Diabetic Durable Equipment Benefit, 50Dual Choice, 10

EElection of Coverage, 11Emergency Treatment, 21, 22Employees and Pensioners, 9Exclusions

Basic Benefit Exclusions and Limitations, 31General Exclusions and Limitations, 56Major Medical Exclusions and Limitations, 37

GGeneral Exclusions, 56GENERAL EXCLUSIONS AND CLAIMS

REVIEW PROCEDURES, 55

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HHospice Care, 26Hospital Benefits, 25, 42How to Claim Additional Medical Benefits, 52How to Claim Basic Hospital-Medical-Surgical

Benefits, 31How to Claim Major Medical Benefits, 38How to Claim Medicare Benefits, 43

IIn PPO Area Emergency Treatment, 21Injectables Benefit, 48

KKidney Dialysis Benefit, 49

LLifetime Maximum, 35Loss of Eligibility, 12

MMaintenance of Benefits, 24MAJOR MEDICAL BENEFITS, 34Major Medical Exclusions and Limitations, 37Mammograms, 29Maternity, 30Medical and Surgical Benefits, 42Medical-Surgical Benefits, 26Medicare Enrollment, 40Mental Health Benefits, 30, 43

NNewborn Nursery Care, 25

OOphthamology Benefit, 51OTHER ILWU-PMA WELFARE PLAN

PROGRAMS, 60Out of PPO Area Urgent or Emergency

Treatment, 21Outpatient Diagnostic X-Ray And Laboratory

Benefits, 28

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PPap Smears, 29Preferred Provider Organization (PPO), 18Prosthetic Device

Initial Device, 36Subsequent Artificial Limbs and Eyes, 50Mastectomy, 22

Providers of Service, 16

QQualified Dependents, 9

RRequest for Claim Review, 58Routine Physical Examination for Children, 28

SService Area, 16Skilled Nursing Facility, 25Special Rights Upon Childbirth, 22Speech Therapy, 30Stop Loss Provision, 35Subrogation/Reimbursement-Third-Party

Liability, 19Subsequent Artificial Limbs and Eyes, 50Supplemental Benefit Amounts, 41SUPPLEMENTAL HOSPITAL- MEDICAL -

SURGICAL BENEFITS FOR MEDICAREELIGIBLES, 40

Supplemental Plan Exclusions, 43Supplementary Accident Benefit, 52

UUsual, Customary and Reasonable Charges

(UCR), 16

VVoluntary Case Management, 20Voluntary Hospital Utilization Review, 20

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