CRCC Benefits

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Comprehensive Medical Benefits
The Plan offers you and your eligible dependents comprehensive medical benefits including coverage for many hospital & physician services, in network surgi-centers, chiropractic care, diagnostic x-ray, imaging and lab tests, durable medical equipment, emergency room physician services, skilled nursing, home health, hearing aids, infertility benefits, maternity benefits, mental health and substance abuse and organ transplants.

When you use a PPO in-network provider, you will receive a higher level of benefits. The Plan pays as follows:

BCBS PPO In-Network Provider	80% paid by Plan 20% paid by you
Non PPO Out of Network Provider	60% paid by Plan 40% paid by you

All comprehensive hospital and professional benefits are subject to the calendar year deductibles and out–of-pocket maximums. PPO in-network and non-PPO out-of-network deductibles and out-of-pockets maximums are separate and cannot be combined. The Plan does not pay for expenses above reasonable and customary charges for non-PPO out-of-network providers.

In certain circumstances, the Plan provides coverage for physical, occupational and speech therapies. In the case of dependent children over the age of 18 months, the Plan has a Developmental Disabilities benefit.

The Plan also provides coverage for certain preventative care, like immunizations and colorectal screening, mammograms and more.

Please refer to the Schedule of Benefits for more information on these benefits. Click here for the Schedule of Benefits.

Preferred Provider Organization
PPO vs Non PPO: Knowing the Difference Saves you Money

The Plan offers you access to a Preferred Provider Organization (PPO) through BCBS. When you or other eligible members of your family use a PPO provider physician and/or hospital, you save money both for your family and the Plan. BCBS has agreements with providers that participate in their network (PPO providers) to charge a negotiated dollar amount. Doing so saves you money in two ways: 1) The overall cost of the service is lower as a result of negotiated discounts and 2) the Plan typically pays a higher percentage of the covered expenses.

If your in-network PPO physician refers you to a hospital or facility, be sure to ask if it is “in-network.” As the chart below shows using healthcare providers in the PPO network, you can maximize your medical benefits and save money for yourself and the Fund.

Example of Network Savings: John Smith has a knee replacement surgery on January 5, 2011.
	In-Network BCBS Provider	Out-of-Network Provider
Cost of single knee replacement	$70,000	$70,000
Network Discount	($30,000)	n/a
Total charges for consideration	$40,000	$54,000***
Participant Pays * (Deductible, coinsurance)**	$2,300	$22,600***
Plan Pays	$37,700	$47,400

* In this example, all covered in-network benefits for the remainder of the 2011 calendar year will be paid at 100% as John's deductible and his Annual Co-Insurance Maximum have been met.

** In-network and out-of-network deductible and coinsurance limits are separate.

*** The amounts charged for out-of-network medical expenses are subject to the Reasonable and Customary Allowances as adopted by the Fund. Amounts over the Reasonable and Customary Allowance ($16,000), plus deductible ($600) and Co-Insurance ($6,000) are the Covered Individual's responsibility.

Be Sure to “Make the Call” before all Hospital Admissions

If you are NOT YET Medicare-eligible, you or a family member must call BlueCross BlueShield's Medical Services Advisory (MSA) within one business day BEFORE you or a dependent are admitted to the hospital or within two business days AFTER emergency or maternity care admissions. If you do not, you will be required to pay a $500 penalty for each hospital admission in addition to any Deductibles and Coinsurance that may apply. Required notification applies to both In-Network PPO and Out-of-Network Non-PPO hospitals.

REMEMBER - MAKE THE CALL
CALL BCBS MSA at 1-800-255-5192

To Find a BCBS PPO In-Network Provider
To see if a Physician or Hospital is a PPO In-Network provider contact BlueCross BlueShield of Illinois at 1-800-810-2583 or visit their website at www.bcbsil.com.

Calendar Year Deductible
The calendar year deductible is the amount of covered medical expenses a participant or dependent pays each calendar year before benefits become payable by the Plan with respect to Comprehensive Medical Benefits. The deductible applies to both hospital & physician expenses.

The calendar year deductible applies only once in any calendar year, even though an individual may have multiple injuries or illnesses during the year.

	In-Network PPO Provider	Out-of-Network Non-PPO Provider*
Calendar Year Deductible	$300/Individual	$600/Individual or
Calendar Year Deductible	$900/Family (3 or more)	$1800/Family (3 or more)
PPO in-network and non-PPO out-of-network deductibles are separate and CANNOT be combined to reach maximums.

Deductible Carryover
Any covered medical expenses incurred in the last three (3) months of a calendar year (October, November and December) applied toward the PPO in-network or non-PPO out-of-network calendar year deductible may also be applied to the calendar year deductibles for the next calendar year.

Coinsurance and Co-Payments
The coinsurance amount is the participant’s or dependents share of the cost of covered services or covered supplies expressed as a percentage. Coinsurance amounts are only applicable to expenses covered by the Plan. Each year, you must satisfy the calendar year deductible (either individual or family maximum), the Plan generally pays a percentage of the covered hospital and physician charges and you pay the rest up to the out-of-pocket maximum as follows:

	In-Network PPO Provider	Out-of-Network Non-PPO Provider*
Hospital & Physician Expenses	80% paid by Plan 20% paid by you	60% paid by Plan 40% paid by you
*The Plan does not pay amounts over the reasonable and customary allowance. Amounts over the reasonable and customary allowance are your responsibility. PPO In-Network and non-PPO out-of-network deductibles and out-of-pocket maximums are separate and CANNOT be combined to reach maximums.

A co-payment (also called co-pay) is a flat dollar amount. For example, when you go to the emergency room or a pharmacy, you pay a co-payment and the Plan pays the remaining reasonable and customary allowances in accordance with Plan provisions.

Out-of-Pocket Maximum
The Plan limits the amount you pay out-of-pocket in a calendar year under your Comprehensive Medical and for both physician & hospital expenses. After you satisfy the calendar year deductible (either individual or family maximum) and the maximum coinsurance amounts, the Plan pays 100% of any additional reasonable and customary covered medical expenses for the remainder of the calendar year.

	In-Network PPO Provider	Out-of-Network Non-PPO Provider*
Hospital & Physician Expenses	$2,000 per Individual $6,000 Family Maximum (3 or more)	$6,000 per Individual $18,000 Family Maximum (3 or more)
*The Plan does not pay amounts over the Reasonable and customary allowance. Amounts over the reasonable and customary allowance are your responsibility. PPO in-network and non-PPO out-of-network out-of-pocket expenses are separate and CANNOT be combined to reach maximums.

Hospital Benefits
The Plan pays up to 180 days of hospital confinement per eligible participant or dependent each calendar year.

REMEMBER - MAKE THE CALL
CALL BCBS MSA at 1-800-255-5192

BEFORE a scheduled hospital admission, or within 2 business days after an emergency admission. This applies to all hospital admissions. Failure to call will result in you being responsible for a $500 Penalty.

Outpatient Hospital Care
The Plan covers medically necessary treatment in connection with outpatient surgery, outpatient diagnostic x-ray and laboratory for a non-occupational (not work related) illness, injury or accident as described below. Outpatient cobalt and deep x-ray treatment and chemotherapy are covered whether or not initial treatment was given as an inpatient.

Outpatient Surgi-Center Care
The Plan covers your medically necessary outpatient surgical facility fees for non-occupational (not work related) illnesses, injuries or accidents when prescribed by a physician. This benefit is available as long as you or your dependent is eligible for benefits under the Plan when services or supplies are rendered.

When you use a PPO in-network provider, you will receive a higher level of benefits. The Plan pays as follows:

BCBS PPO In-Network Hospital	80% Coverage (subject to a Calendar Year Deductible)
BCBS PPO In-Network Surgi Center	80% Coverage (subject to a Calendar Year Deductible)
Non-PPO Hospital	60% Coverage (subject a to Calendar Year Deductible)
Surgi Center Facility not affiliated with the BCBS PPO network or a Hospital (i.e., Free Standing)	NO COVERAGE (zero payment)

Please refer to the Schedule of Benefits for more information on these benefits. Click here for the Schedule of Benefits.

Adverse Claim Determination Appeal Process

The Patient Protection and Affordable Care Act (“PPACA”) requires health plans to maintain an enhanced internal claims and appeals process and a new external review process for rescission of coverage and adverse benefit determinations (a claim that has been denied in whole, or in part). The information below will summarize the regulations and guidance on both the enhanced internal review process and the external review process.

For appeal purposes, claims are grouped into three different categories:

1. Pre-Service Claims – a pre-service claim in one in which a pre-authorization is required before a service can be performed. Adverse benefit determinations on pre-service claims are appealable; however this Plan does not require you to get prior authorization or approval before services are rendered and there are no preexisting condition exclusions under this Plan.

2. Post-Service Claims – a post-service claim is one in which a claim has been adjudicated (processed) after the service was rendered. Adverse benefit determinations on post-service claims are appealable. A post-service claim, also known as a claim for benefits, contains all of the following information:

a. patient’s name and date of birth

b. participant’s name and social security number or the identification number assigned by the Fund Office

c. date of service,

d. name of the health care provider and tax identification number

e. address of health care provider,

f. procedure code and its corresponding meaning;

g. place of service

h. the claim amount; and

i. denial code and it’s corresponding meaning.

3. Urgent Care Claims – an urgent care claim is one in which the patient’s health would be in serious jeopardy or delay would jeopardize the patient’s ability to regain maximum function or, in the opinion of patient’s physician, he/she may experience pain that cannot be adequately controlled while waiting for a decision on whether the procedure or service is approved for coverage. Adverse benefit determinations on urgent care claims are appealable; however this Plan does not require you to get prior authorization or approval before services are rendered and there are no preexisting condition exclusions.

Internal Review of Claims

An Explanation of Benefits (EOB) serves as the notice of an adverse benefit determination when payment of a claim for benefits has been denied, in whole or in part, for the reasons stated on the EOB. If you believe the determination was made in error, you have certain appeal rights. Only a Participant, patient or an Authorized Personal Representative may appeal an adverse benefit determination. The information below describes the Fund’s Internal Review process.

I. Determine if you have a claim for benefits.

A. A claim for benefits (also referred to as a “post-service claims) must contain all of the following information: patient’s name and date of birth, participant’s name and social security number or the identification number assigned by the Fund Office, date of service, name of the health care provider and tax identification number, address of health care provider, procedure code and its corresponding meaning; place of service, the claim amount; and a denial code and it’s corresponding meaning.

B. Because this Plan does not require a service or procedure to be pre-authorized and there are no preexisting condition exclusions, the only claims that generally can be appealed under this Plan are post-service claims that have been processed and denied in whole or in part.

C. Only a participant, patient or an Authorized Personal Representative has the right to appeal a claim for benefits that was denied in whole or in part.

D. To designate an Authorized Personal Representative, log on to the Fund’s website at www.crccbenefits.org. On the left hand side of the screen under “Health Plan” select “Form” Scroll down and print an Authorized Personal Representative Designation form. By completing this form, you are requesting the Fund Office to provide and/or communicate with the person or entity (e.g., your doctor) you designate as your authorized personal representative.

E. A request by a provider or participant for information on whether a certain procedure, prescription, treatment plan or other similar request is covered by the Plan (often referred to as a “pre-determination of benefits request”) is not considered a claim for benefits; and therefore not appealable.

II. Determine if you are filing a timely appeal.

A. If a post service claim for benefits has been denied, in whole or in part, the Participant, Patient or Authorized Personal Representative have no more than 180 days after the receipt of an adverse benefit determination to file an appeal.

III. To Request an Appeal of an Adverse Benefit Determination

A. To file an appeal with the Board of Trustees, log on to the Fund’s website at www.crccbenefits.org. On the left hand side of the screen under “Health Plan” select “Forms.” Scroll down and print an Appeal Form. Complete the form in its entirety.

B. All appeals must be in writing, contain the signature of the participant, patient or authorized personal representative and addressed to the Board of Trustees.

C. Your written appeal should include evidence or specific facts and benefit plan provisions that support your claim for benefits. If you have additional information that pertains to your appeal, you may attach it to the Appeal Form.

D. Submit the completed Appeal Form and any additional information to substantiate your appeal to:

Scan & Email: Appeals@crccbenefits.org

Fax: Chicago Regional Council of Carpenters

Welfare Fund

Attn: Appeals Committee

Fax Number: 312-951-1515

(Note: Write the Participant’s name and

ID number on each page)

Mail: Chicago Regional Council of Carpenters

Welfare Fund

Attn: Appeals Committee

12 East Erie Street 7^th floor

Chicago, IL 60611

IV. Upon Appeal, a Covered Individual has the Right:

A. To receive, upon written request, copies of all documents relevant to the claim;

B. To designate an authorized personal representative (who may be an attorney);

C. To request, free of charge, a copy of relevant information if the covered individual’s claim is denied based on internal rules, guidelines, protocol or other similar criteria;

D. To request, free of charge, a copy of an explanation of the scientific or clinical judgment that is the basis of the adverse claim determination, if the covered individual’s claims is denied based on medical necessity, experimental treatment or similar exclusion or limit

E. To be advised of the identity of any medical expert; and

F. The covered individual may:

1. Submit additional material, including comments, statements, or documents; and

2. Request, free of charge, all relevant information. A document, record or other information is considered relevant if it:

a. Was relied upon by the Plan in making the decision;

b. Was submitted, considered, or generated (regardless of whether is was relied upon; or

c. Demonstrates compliance with Claim processing requirement.

G. To receive copies or all new or additional information considered, relied upon or generated during the appeal as well as any new or additional rationale for the denial, if any; and

H. To challenge the denial of a claim by filing a lawsuit in court, seeking review of the Funds decision under section 502(a) of ERISA. Such lawsuit can be filed only after a covered individual has followed and exhausted the Fund’s internal Appeal procedures

V. Preliminary Review

A. The Plan will complete a preliminary review of the request within five (5) business days of the Plan’s receipt of your request for an appeal to determine whether:

i. You are/were covered under the Plan at the time the health care item or service is/was requested or, in the case of a retrospective review, were covered under the Plan at the time the health care item or service was provided;

ii. The Adverse Determination does not relate to your failure to meet the requirements for eligibility under the terms of the Plan; and

iii. You have provided all of the required information and forms to process your appeal.

VI. Review by the Appeals Committee of the Board of Trustees

A. Properly filed appeals are reviewed at the next regularly scheduled appeals meeting of the Trustees, who meet at least quarterly.

i. The Trustees will mail their decision to the covered individual within five (5) business days after making a determination.

B. If your appeal is denied, you have the right to initiate a lawsuit under ERISA section 502(a) or request an external review from an independent review organization.

i. Any lawsuit must be initiated within twelve months of the denial on review.

External Review of Claims

If your appeal of a claim is denied by the Appeal Committee of the Board of Trustee, you may request further review by an independent review organization (“IRO”) as described below. Generally, you may only request an external review after you have exhausted the internal review and appeals process described above.

NOTE that if your claim was denied due to your failure to meet the requirements for eligibility under the terms of the Plan, external review is not available.

I. External Review of Standard Claims

Your request for external review of a non-urgent claim must be made, in writing, within four (4) months of the date the Explanation of Benefits indicating an adverse benefit determination or the date of the letter advising of an adverse Appeal Claim Benefit Determination which ever is greater. For convenience, the determination(s) referred to below are “Adverse Determination(s),” unless it is necessary to address them separately.

The Plan’s internal review and appeals process generally must be exhausted before external review is available. External review of claims will only be available for adverse appeal benefit determinations. To request an external review, log on to the Fund’s website at www.crccbenefits.org. On the left hand side of the screen under “Health Plan” select “Forms.” Scroll down and print an “External Review Form.” Follow the directions provided and submit to the Fund Office.

A. Preliminary Review

1. The Plan will complete a preliminary review of the request within five (5) business days of the Plan’s receipt of your external review request to determine whether:

(a) You are/were covered under the Plan at the time the health care item or service was requested or, in the case of a retrospective review, were covered under the Plan at the time the health care item or service was provided;

(b) The Adverse Determination does not relate to your failure to meet the requirements for eligibility under the terms of the Plan;

(c) You have exhausted the Plan’s internal claims and appeals process (except, in limited, exceptional circumstances); and

(d) You have provided all of the required information and forms to process an external review.

2. The Plan will notify you in writing within one (1) business day of completing its preliminary review if your request meets the requirements for external review. If applicable, this notification will inform you:

(a) If your request is complete but not eligible for external review, in which case the notice will include the reasons for its ineligibility, and contact information for the Employee Benefits Security Administration (toll-free number 866-444-EBSA (3272)).

(b) If your request is not complete, in which case the notice will describe the information or materials needed to make the request complete, and allow you to perfect the request for external review within the four (4) month filing period, or within a 48-hour period following receipt of the notification, whichever is later.

B. Review by Independent Review Organization

1. If the request is complete and eligible, the Plan will assign the request to an IRO. The IRO is not eligible for any financial incentive or payment based on the likelihood that the IRO would support the denial of benefits. The Plan may rotate assignment among IROs with which it contracts.

2. Once the claim is assigned to an IRO, the following procedure will apply:

(a) The assigned IRO will timely notify you in writing of the request’s eligibility and acceptance for external review, including directions about how you may submit additional information regarding your claim (generally, such information must be submitted within ten (10) business days).

(b) The Plan will provide, within five (5) business days after the assignment to the IRO, documents and information it considered in making its Adverse Determination.

(c) If you submit additional information related to your claim, the assigned IRO must within one (1) business day forward that information to the Plan. Upon receipt of any such information, the Plan may reconsider its Adverse Determination that is the subject of the external review. Reconsideration by the Plan will not delay the external review. However, if upon reconsideration, the Plan reverses its Adverse Determination, it will provide written notice of its decision to you and the IRO within one (1) business day after making that decision. Upon receipt of such notice, the IRO will terminate its external review.

(d) The IRO will review all timely received information and documents. In reaching a decision, the IRO will review the claim de novo (as if it is new) and will not be bound by any decisions or conclusions reached during the Plan’s internal claims and appeals process. However, the IRO will be bound to abide by the terms of the Plan to ensure that the IRO decision is not contrary to the terms of the Plan, unless the terms are inconsistent with applicable law. The IRO also must abide by the Plan’s requirements for benefits, including the Plan’s standards for clinical review criteria, medical necessity, appropriateness, health care setting, or level of care of a covered benefit. In addition to the documents and information provided, the assigned IRO, to the extent the information or documents are available and appropriate, may consider additional information, including information from your medical records, any recommendations or other information from your treating health care providers, any other information from you or the Plan, reports from appropriate health care professionals, appropriate practice guidelines, the Plan’s applicable clinical review criteria and/or the opinion of the IRO’s clinical reviewer(s).

(e) After the IRO receives the request for the external review, the assigned IRO will provide written notice of its final external review decision to you and the Plan within 45 days.

(f) The assigned IRO’s decision notice will contain:

(i) A general description of the reason for the request for external review, including information sufficient to identify the claim (including the date or dates of service, the health care provider, the claim amount (if applicable), the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning, and the reason for the previous denial);

(ii) The date that the IRO received the assignment to conduct the external review and the date of the IRO decision;

(iii) References to the evidence or documentation, including the specific coverage provisions and evidence-based standards, considered in reaching its decision;

(iv) A discussion of the principal reason(s) for its decision, including the rationale for the decision and any evidence-based standards that were relied upon in making its decision;

(v) A statement that the determination is binding except to the extent that other remedies may be available to you or the Plan under applicable State or Federal law;

(vi) A statement that judicial review may be available to you; and

(vii) Current contact information, including phone number, for the health insurance consumer assistance or ombudsman established under the Affordable Care Act to assist with external review processes.

II. Expedited External Review of Claims

You may request an expedited external review if:

1. You receive an Initial Adverse Benefit Determination that involves a medical condition for which the timeframe for completion of an internal appeal would seriously jeopardize your life or health, or would jeopardize your ability to regain maximum function, and you have filed a request for an urgent care internal appeal; or

2. You receive an adverse Appeal Claim Benefit Determination that involves a medical condition for which the timeframe for completion of a standard external review would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function; or, you receive an adverse Appeal Claim Benefit Determination that concerns an admission, availability of care, continued stay, or health care item or service for which you received emergency services, but you have not yet been discharged from a facility.

A. Preliminary Review

Immediately upon receipt of the request for expedited external review, the Plan will complete a preliminary review of the request to determine whether the requirements for preliminary review set forth above, in section I.A.1, are met. The Plan will immediately notify you as to whether your request for review meets the preliminary review requirements, and if not, will provide or seek the information described above in section I.A.2.

B. Review by Independent Review Organization

(a) Upon a determination that a request is eligible for expedited external review following the preliminary review, the Plan will assign an IRO. The Plan will expeditiously provide or transmit to the assigned IRO all necessary documents and information that it considered in making its Adverse Determination.

(b) The assigned IRO, to the extent the information or documents are available and the IRO considers them appropriate, must consider the information or documents described in the procedures for standard review, at above section I.B. In reaching a decision, the assigned IRO must review the claim de novo (as if it is new) and is not bound by any decisions or conclusions reached during the Plan’s internal claims and appeals process. However, the IRO will be bound to abide by the terms of the Plan to ensure that the IRO decision is not contrary to the terms of the Plan, unless the terms are inconsistent with applicable law. The IRO also must abide by the Plan’s requirements for benefits, including the Plan’s standards for clinical review criteria, medical necessity, appropriateness, health care setting, or level of care of a covered benefit.

(c) The IRO will provide notice of the final external review decision, in accordance with the requirements set forth above in section I.B.f, as expeditiously as your medical condition or circumstances require, but in no event more than seventy-two (72) hours after the IRO receives the request for an expedited external review. If the notice is not in writing, within forty-eight (48) hours after the date of providing that notice, the IRO must provide written confirmation of the decision to you and the Plan.

III. After External Review

(A) If the final external review reverses the Plan’s Adverse Determination, upon the Plan’s receipt of notice of such reversal, the Plan will immediately provide coverage or payment for the reviewed claim.

(B) If the final external review upholds the Plan’s Adverse Determination, the Plan will continue not to provide coverage or payment for the reviewed claim. If you are dissatisfied with the external review determination, you may seek judicial review as permitted under ERISA Section 502(a).