Kingston Trust Fund
Health Care Updates - February 2004
Health Care Clarifications - September 2003
Scroll Down For or Navigate Directly To:
TRUST AMENDMENTS and MODIFICATIONS
The Trustees of the Kingston Trust Fund have a fiduciary responsibility
to the Trustís health plan. As a result of changes in the health care industry
and impacts on the plan, the following amendments and modifications have been
adopted and are effective July 1, 2003.
PPO=100% of the first $500, then 90% (other than ER)
CENTER/OUTPATIENT HOSPITAL: PPO=90%,
90% OOA, 80% NPPO. Includes all services, supplies, and Rx related to an
ambulatory surgical center or outpatient hospital.
PPO/OOA/NPPO= 100% after $50 copay. X-Ray and Lab billed separately subject to
separate applicable copays.
HOSPITAL ADMISSION: PPO/OOA=$100 copay per admission, NPPO=$250 copay.
Copay waived for Kingston Hospital. All:Limit:$300/yr.
HOSPITAL SUPPLIES:PPO/OOA=90%, NPPO=80%. Includes all hospital
services,supplies, and Rx, other than rm. and board, including ambulatory
NEGOTIATED SERVICES WITH NPPO PROVIDERS: 90% after NPPO deductible.
OOA=90%, NPPO=80%, after $15 copay for outpatient therapies.
OOA=90%, NPPO=80%, Max. 30 visits/yr. and one/day.
THERAPY(Outpatient): PPO=100%, OOA=90%,
NPPO=80% after $15 copay. Max. 50 visits /yr. and one/day.
PHYSICIAN OFFICE VISIT
(POV): PPO=100%, OOA=100%, NPPO=80%,
after copay($10 Gen. Practitioner($15.OOA), $20 Specialist)) plus 10% of any
charges in excess of $250.
PPO/OOA=100% for Centers of Excellence(based on approved National
Accreditation Specialization), Otherwise 90%. NPPO=80%.
PPO/OOA/NPPO=100% after $20 copay per trip, pre-approved.
IMMUNIZATIONS: PPO=100%, OOA=90%,
NPPO=80%. In all cases, 50% for vaccinations due to terrorist threat of
National Vaccination Program.
schedule applies to all medications even if given by a PPO provider (NPPO
deductible), NPPO=80% (50% for terrorist threat national vaccinations).
required based on medical necessity.
PPO/OOA/NPPO=50% to max of $150/yr.
Not covered if elective for preventative treatment. Separate from physical
exam. Discounted NHAI rate with preferred providers for elective.
Rules: Memberís coinsurance portion of the cost will be credited towards any
deductible or out of pocket limit under this plan.
after $15 copay(OOA based on UCR),80% NPPO.
*OOA status does not
apply to foreign residence, except as approved. Generally, where the NPPO is
covered 80%, the OOA will be covered to 90%.
First three (3) prescriptions, $5 generic, $15 Brand for 30 day supply. ANY
Rx AFTER 3rd REFILL WILL BE SUBJECT TO HIGHER COPAYS UNLESS FILLED
BY MAIL ORDER: 25% COPAY FOR GENERIC AND BRAND DRUGS AFTER 3rd
REFILL. Call NHAI for Vacation Overrides and any variances on prescriptions.
MAIL ORDER: $10 copay
Generic, $25 copay Brand for 93 day supply.
Covered same as any other Rx.
Only covered if enrolled in Infertility/IVF Program.
MAJOR MEDICAL Rx:
PPO= 90%, OOA= 90%, NPPO=80%
Certain injections (i.e., aids medication), covered as Major Medical and
pre-authorized, must be paid for by the member and a claim submitted for
Rx COORDINATION of
BENEFITS: The plan will pay the
portion of the out of pocket expense under the primary plan LESS whatever
copay would have been paid under the plan. The out of pocket expense under the
primary plan must be at least $25 or more for any Rx to be considered under
the COB provisions of this plan.
MENTAL/ADDICTIVE: All Mental Health benefits will be provided under the
NHAB as the exclusive provider for mental, nervous, and addictive treatment.
OUTPATIENT: PPO=100% after NHAB
copay while in compliance. Otherwise, benefits will be limited to 50% after
the NHAB copay and the patient will be responsible for the balance. Benefits
limited to $5000/year.
FAILURE TO COMPLY-Outpatient
Addictive Treatment Program: wil result in termination of that program. This
includes any requirement for drug testing. If an individual continues to abuse
drugs and/or alcohol while attending a treatment program, the program is
doomed to failure. This situation will be treated the same as though the
individual had been admitted for detoxification. An inpatient treatment
program will be required to be completed to insure complete detoxification
before providing approval for outpatient treatment. Outpatient programs are
subject to submission of a treatment plan and pre-approval. As a condition of
participation in an outpatient treatment program without first completing an
inpatient program, the patient may be required to submit to periodic drug
testing. After two negative tests, approval of the treatment program will be
suspended and further outpatient treatment will not be covered until the
patient completes a detoxification program inpatient and is medically and
mentally capable of transferring to an outpatient program. No substance abuse
treatment program will achieve any level of success until the patient is
willing to discontinue their abusive behavior and agrees to remain in
compliance with the terms of the treatment program.
FAILURE TO COMPLETE-In-Patient
program for substance abuse penalty: Your copay will be increased by 20% and
the plan benefits will be decreased by 20% if you do not complete or refuse to
complete any addictive or substance abuse treatment program in its entirety,
including premature discharge against medical advice. If the continuing care
program following any confinement program is not completed, the basic plan
copay for any second or third treatment will be reduced by 10%. The plan copay
for the second treatment is reduced from 70% to 80%.
You must successfully
complete an aftercare program after the first episode of inpatient care to be
eligible for further coverage.
NHAB Provider, 70% Non NHAB
PPO=100% after $15 copay to max $60/visit($50 Massage),OOA/NPPO=75% to max of
$50/visit. 30 visits/yr (Massage 15);Total max=$2500 for all
Massage: in excess of 3 visits during a 60-day period must be
Board of Trustees - 2003-2004:
||Term Expires During
|Laura Sexton - Treasurer
|Hugh Spoljaric - Chairman
Schedule of Trust Meetings
All of the meetings below are scheduled to be in the KHS Cafeteria:
- September 30, 2003
- November 24, 2003
- January 20, 2004
- May 25, 2004