MODEL 109: SPOUSES OF RETIREES
(SUPPLEMENTAL TO
PRIMARY INSURANCE)
Plan 11
The Association pays the deductible and/or coinsurance on any charges APPROVED by the primary insurer. Claim submissions must have a copy of the itemized charges showing procedures and diagnosis, as well as a copy of the primary insurer’s Explanation of Payment or Explanation of Benefits. Plan payments may not exceed Usual, Customary and Reasonable (UCR) charges.
In addition, the Association provides the following benefits, whether or not they are covered by the primary insurer.
BENEFIT
* WABASH PAYSColostomy Bags (Only)
50% reimbursementDietary Consultation up to $50.00 once per year
Eye Exam one exam per year at 100% up to a maximum of $40.00
Mammogram (screening) 80% limited to one per year
Preventive Care (routine physicals, immunizations, etc.) 100%
Not Covered
(1) The Association will not provide coverage for any benefit reduction by the primary insurer due to the patient’s failure to comply with the primary insurer’s rules. For example, if the primary insurer requires that hospital admissions be pre-certified, and either assesses a penalty or pays a lower level of benefits because the patient failed to pre-certify an admission, the Association will not provide benefits for the amount of the benefit reduction or penalty. If the primary insurer normally pays 80% of covered charges, but reduces their payment to 65% because of failure to pre-certify, the Association will only pay 20% of the covered charges. The difference between the normal 80% benefit and the 65% paid by the primary insurer will be the patient’s responsibility.
(2) Prescription drugs