The Trust has adopted Care Management Programs to help you obtain cost effective care, and save both you and the Trust money. The components of your care management programs described on the following pages are:

• Preferred Provider Organization (PPO)
• Hospital Utilization Review Program (UR)
• Hospital Discharge Planning and Case Management
• Convalescent Nursing Home Expense Benefit
• Home Health Care Benefit
• Hospice Care Benefit

Preferred Provider Organization (PPO)
Use of PPO Providers will result in a greater level of benefits.

A Preferred Provider Organization (PPO) is available to employees and their dependents who are covered under the Western Teamsters Welfare Trust in most areas. Please see your booklet insert for additional information about your PPO plan and other care management programs.

PPO networks are made up of individual hospitals and doctors who have a written agreement to furnish medical services and supplies at reduced costs. If you choose to use PPO providers, you will receive an increased benefit, however, you are not required to use PPO hospitals and doctors - you may seek care from any eligible provider you choose.

Provider directories are available from your Area Administrative Office. These list the providers (doctors, hospitals, labs, etc.), who are participating in the PPO in your area.

Hospital Utilization Review Program
All hospital admissions whether PPO or non-PPO hospitals must be pre-authorized (except for emergencies). A review determines the length of stay, based on the patient’s condition, that will be considered eligible for indemnity medical benefits. Each inpatient hospital admission is reviewed by your Utilization Review company before the patient enters the hospital. If your hospital stay is not pre-authorized, benefits will be paid at reduced rates, as follows:

• PPO hospital charges will be paid at the reduced rate of 80% of eligible expenses if admission is not pre-authorized.
• Non-PPO hospital charges will be paid at the reduced rate of 65% of eligible expenses if admission is not pre-authorized.

If the admit is an emergency, your Utilization Review company must be notified within 48 hours after admission.

Admissions for childbirth are allowed for not less than 48 hours following a vaginal delivery or 96 hours following a cesarean section. You may be discharged earlier so long as you and your provider agree.

Admissions for inpatient and alternative psychiatric or chemical dependency treatment must be authorized by Health Management Center.

Hospital Discharge Planning and Case Management
Discharge planning is beneficial when you require continued medical care but not inpatient hospitalization. Your Utilization Review company employs case management nurses who will work with you, your family, your physician and the hospital staff to develop a discharge plan that follows your release from the hospital. Your case manager can help arrange home health care, skilled nursing care and hospice care.

Convalescent Nursing Home Benefit Following Hospitalization
This coverage provides benefits for a covered convalescent nursing home confinement starting within fifteen days after you or a covered dependent have been in a hospital at least three days and have received benefits. The confinement must be recommended by your doctor for the same condition which caused your hospitalization.

Benefits are payable for room and board and other services and supplies furnished by the home for medically necessary care. The patient must be under continuous care of his or her doctor and require 24-hour nursing care. Personal items and professional services such as private duty nursing are excluded.

Benefits for Convalescent Nursing Home Expenses are limited to 60 days for all care due to the same or related causes and are paid after the deductible at 90% for preferred providers and 75% of Usual Customary and Reasonable for non-PPO providers.

Home Health Care Benefit
The Plan will pay Eligible Expenses for home health care that is provided as part of a Home Health Care Treatment Plan to treat an illness or injury. Home health care benefits pay 100% of Eligible Expenses listed below for services and supplies furnished by a Home Health Care Agency, subject to the following conditions:

• The patient is under the care of a doctor who submits a “home health care plan”. A “Home Health Care Treatment Plan” is a written program for care and treatment in the patient’s home; and
• The services and supplies are furnished while, if it were not for the home health care, inpatient confinement in a hospital, convalescent nursing home or skilled nursing facility would be required.

The Eligible Expenses are the Home Health Care Agency’s charges for the following services and supplies ordered by the doctor under the home health care plan and furnished in the patient’s home:

• Part-time or intermittent nursing provided or supervised by a Registered Nurse (R.N.).
• Part-time or intermittent home health aide services, primarily for the patient’s care.
• Physical, occupational, speech or respiratory therapy by a qualified therapist.
• Nutrition counseling provided by or under the supervision of a registered dietitian.
• Medical supplies, laboratory services, drugs and medications prescribed by a doctor.

Home health care benefits are limited to 130 visits per person, in a calendar year. Each visit by a representative of a home health care agency, other than a home health aide, shall be counted as one visit. In the case of visits by home health aides, each visit lasting four hours or less is counted as one visit. If a visit exceeds four hours, each four hours or fraction thereof is counted as a separate visit.

Care Management Programs Provided by Beech Street
For Hospital Utilization Review and Pre-certification, Medical Case management, or to Locate a Preferred Provider, call toll-free at 1-877-891-7983. For a Preferred Provider Directory contact your area Administrative Office.

Hospice Care Benefit
Benefits are payable for hospice care for a terminally ill person. Under a hospice care program, treatment is normally rendered in the patient’s home. It offers a less expensive, and often more humane alternative to hospital confinement for the terminally ill. This benefit also provides for some of the needs of the other family members.

This coverage pays benefits for charges incurred for a terminally ill person while in a hospice care program. Certification of the terminal illness must be given to the Area Administrative Office in order for hospice coverage for a terminally ill person to be considered.

The benefits will be paid if the hospice services or the hospice stay is:

• Provided while the terminally ill person is an eligible individual;
• Ordered by the attending physician as part of the hospice care program;
• Charged by the hospice care program; and
• Provided within 6 months of the terminally ill person’s entry or re-entry (after a remission period) in the hospice care program.

The coverage will pay the charges incurred for all hospice services for one period of care in the hospice care program up to the Maximum Hospice Benefit of $5,000.

Bereavement Benefits for Families of Those in a Hospice Program
This part of the Hospice Care Benefit provides benefits for charges incurred for counseling services for the family unit (an employee and any covered dependents), if ordered and received under the hospice care program.

The benefits will be paid if:

• On the day prior to death the terminally ill person was in the hospice care program,
• The person seeking bereavement benefits is a member of the family unit and a covered individual, and
• The charges are incurred by the family unit within three months following the date the terminally ill person dies.