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Kingston Teachers' Federation
 P.O. Box 4461       Kingston, N.Y. 12401        Phone/Fax (845) 338-5422       Hugh M. Spoljaric, President
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Kingston Trust Fund

Health Care Updates - February 2004

Health Care Clarifications - September 2003

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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.

ACCIDENTS: PPO=100% of the first $500, then 90% (other than ER)

AMBULATORY/SURGICAL CENTER/OUTPATIENT HOSPITAL: PPO=90%, 90% OOA, 80% NPPO. Includes all services, supplies, and Rx related to an ambulatory surgical center or outpatient hospital.

ER: 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 centers.

NEGOTIATED SERVICES WITH NPPO PROVIDERS: 90% after NPPO deductible.

OTHER THERAPIES:PPO=100%, OOA=90%, NPPO=80%, after $15 copay for outpatient therapies.

PHYSICAL THERAPY(Inpatient):PPO=100%, OOA=90%, NPPO=80%, Max. 30 visits/yr. and one/day.

PHYSICAL 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.

TRANSPLANTS: PPO/OOA=100% for Centers of Excellence(based on approved National Accreditation Specialization), Otherwise 90%. NPPO=80%.

TRANSPORTATION(Scheduled): PPO/OOA/NPPO=100% after $20 copay per trip, pre-approved.

OTHER COVERED IMMUNIZATIONS: PPO=100%, OOA=90%, NPPO=80%. In all cases, 50% for vaccinations due to terrorist threat of National Vaccination Program.

PREVENTIVE VACCINATION/IMMUNIZATION: PPO=NPPO schedule applies to all medications even if given by a PPO provider (NPPO deductible), NPPO=80% (50% for terrorist threat national vaccinations).

Pre-certification required based on medical necessity.

VISION: PPO/OOA/NPPO=50% to max of $150/yr.

X-RAY/BODY SCANS=Are Not covered if elective for preventative treatment. Separate from physical exam. Discounted NHAI rate with preferred providers for elective.

BODY SCANS-Special Rules: Memberís coinsurance portion of the cost will be credited towards any deductible or out of pocket limit under this plan.

WEIGHT LOSS:PPO/OOA:100% 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%.

Rx BENEFITS: 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.

BIRTH CONTROL: Covered same as any other Rx.

INFERTILITY: Only covered if enrolled in Infertility/IVF Program.

MAJOR MEDICAL Rx: PPO= 90%, OOA= 90%, NPPO=80%

INJECTABLES: 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 reimbursement

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.

SUBSTANCE ABUSE 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.

EMERGENCY TREATMENT/DETOXIFICATION: PPO=90% NHAB Provider, 70% Non NHAB

CHIROPRACTIC/ACUPUNCTURE/MASSAGE: 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          pre-certified.

Board of Trustees - 2003-2004:

Name Term Expires During
Linda Armston 2006
Bob Cunningham
2004
Gail Diamond 2006
Kim Garmire 2005
Bill Tubby 2005
Laura Sexton - Treasurer 2005
Hugh Spoljaric - Chairman N/A

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

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