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  President Sandy Pope
 
 
 

Benefits

 

  GHI Network Out-of-Network Providers
Inpatient Visits Fund pays 100% Deductible and Coinsurance
Physician Visit Fund pays 100% of Negotiated Charge after your $20 co-payment Fund pays 70% of Reasonable & Customary charges after Calendar Year Deductible; participant pays difference
Annual Physical Exam Fund pays 100% of Negotiated Charge after your $20 co-payment Fund pays 70% of Reasonable &Customary charges. Not subject to the Calendar Year Deductible

Well Child Care


1st Year – 6 visits
2nd Year -4 visits
3rd Year – 2 visits
Thereafter – 1 visit

 

Up to age 19;

including necessary immunization

 Fund pays 100% of Negotiated Charge after your $20 co-payment Fund pays 70% of Reasonable & Customary after deductible.

Chiropractic Care/Services

 

Maximum of 30 visits per year.

 Fund pays 100% of Negotiated Charge after your $20 co-payment Fund pays 70% of Reasonable & Customary charges after Calendar Year Deductible; participant pays difference

Mental Health Visits

 

Maximum of 40 (Outpatient) visits per year.

 Fund pays 100% of Negotiated Charge after your $20 co-payment. Covered in-network only.

Physical Therapy, Physical Medicine, & Rehabilitation Speech Therapy

 

Maximum of 30 visits per year.

 Fund pays 100% of Negotiated Charge after your $20 co-payment (out-patient)  
Surgery Fund pays 100% of Negotiated Charge Fund pays 70% of Reasonable & Customary charges after Calendar Year Deductible; participant pays difference
Out Patient Surgery Fund pays 100% of Negotiated Charge Fund pays 70% of Reasonable & Customary charges after Calendar Year Deductible; participant pays difference
Anesthesia Fund pays 100% of Negotiated Charge (no co-payment) Fund pays 100% of Reasonable & Customary charges (no deductible)
Laboratory
Services
 Fund pays 100% of Negotiated Charge (no co-payment) Fund pays 70% of R&C charges after Calendar Year Deductible; participant pays difference
Radiology-X-rays, MRI, Sonograms, C-scan Fund pays 100% of Negotiated Charge (no co-payment) Fund pays 70% of R&C charges after Calendar Year Deductible; participant pays difference
Hospitalization Fund pays 100% of the Negotiated Charge Fund pays 100% of R&C charges; $400 penalty for failure to precertify
Emergency Room Fund pays 100% of Negotiated Charge after a $75 Co-pay
Waived if Admitted

Fund pays 100% of Reasonable & Customary charge after a $75 Co-pay.


Waived if Admitted
Ambulance Fund pays 100% of the Negotiated Charge 70% of Reasonable & Customary after deductible
Hospice
Pre-Certification Required
 Fund pays 100% up to a maximum of 90 days. Precertification required. Covered in-network only.
Home Health Care
Pre-Certification Required.
Up to 200 visits per calendar year
 Fund pays 100% of the Negotiated Charge. Precertification required. Covered in-network only.
Skilled Nursing Facility
Up to 60 days per calendar year
 Fund pays 100% of the Negotiated Charge. Precertification required. Covered in-network only.
Durable Medical Equipment Fund pays 100% of Negotiated Charge. Covered in-network only

Alcohol & Substance Abuse

Up to 40 sessions per year at  Teamster Center Services

Up to a maximum of $45 Per session, plus $20 co-pay.

 Outpatient only

 

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