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Benefits
Amalgamated Retail Insurance Fund
SUMMARY OF PLAN PROVISIONS
This overview was prepared to provide you with a very general
basic description of the plan. It is not the official summary plan
description (SPD) and it is not intended to replace any of the plan
documents or your SPD booklet. Consult the SPD or the plan for a
full description of benefit coverage. In case of any conflict between
this document and the SPD or the plan, the terms of the SPD or the
plan shall govern. To obtain detailed information about the plan,
or to get a copy of the SPD in case you cannot locate yours, call
the funds office at 212-475-3131.
Health Care Coverage
(For Full-Time Employees and Covered Dependents)
Lifetime Maximum
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$1,000,000 lifetime maximum payment per person for all coverage. $50,000 lifetime maximum payment for substance abuse confinements.
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Annual Deductible
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A deductible must be incurred each calendar year for certain expenses before you begin to receive reimbursement of recognized reasonable charges. Out-Of-Network: $500 per person, ($1,500 per family) applies to all expenses. There is no deductible when a Network provider is used or is not available.
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Basic Hospital Coverage
Lifetime Maximum
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Coverage for up to 120 days or $200,000 per confinement. In-Network or Network-Not-Available: Covered at 100%. Out-Of-Network: Subject to annual deductible, covered at 70%.
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Mental Illness and Substance Abuse Confinement
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Coverage for up to 30 hospital inpatient days for mental illness and 30 hospital inpatient days for substance abuse per 12 month period. Substance abuse subject to $50,000 lifetime maximum payment. In-Network or Network-Not-Available: Covered at 100%. Out-Of-Network: Subject to annual deductible, covered at 70%.
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Alternatives to Hospital Inpatient
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Coverage for an Ambulatory Surgical Center, Skilled Nursing or Acute Rehabilitation Facility, Home Health Care, Birthing Center or Hospice. In-Network or Network-Not-Available: Covered at 100%. Out-Of-Network: Subject to annual deductible, covered at 70%.
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Hospital Oupatient
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Coverage for charges billed by a hospital for surgery, chemotherapy, radiotherapy, pre-admission testing, and for emergency treatment within 48 hours of an accident or illness. In-Network: Covered at 100%. Out-Of-Network: Subject to annual deductible, covered at 70%. Network-Not-Available: Emergency illness subject to annual deductible, covered at 80%. Other servisces covered at 100%.
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Major Medical Coverage
Major Medical Coverage
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Covered according to a schedule, subject to the annual deductible, where applicable, and Plan maximums. In-Network: Covered at 85% of Network schedule. Office visits covered at 100% after a $15 copay-ment. Out-Of-Network: Covered at 70% of Network schedule. Network-Not-Available: Covered at 80% of recognized reasonable charges.
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Coverage is provided for:
- Surgery
- Anesthesiology
- Physician Visits in the hospital
- Physician Office Visits — up to 20 visits per calendar year; In-Network $15 copayment per visit
- Chiropractic Office Visits — up to $1,000 Fund payment per calendar year; In-Network $15 copayment per visit
- Podiatric Office Visits — non-surgical visits up to $500 Fund payment per calendar year; In-Network $15 copayment per visit
- Diagnostic and Therapeutic Professional Services
- Ambulance Service
- Supply of Blood — where UNITE/Red Cross program not available
- Medical Equipment, Supplies and Appliances
Weekly Disability Income Coverage (For You Only)
If you are unable to work because of an injury, illness or pregnancy, you are covered for weekly disability income. You can receive from $26 to $200 a week for up to 26 weeks for illness and 26 weeks for injury in a 12 month period.
Dental Care Coverage (For You And Your Covered Dependents)
You are covered for eligible dental and orthodontic services, subject to an annual deductible of $75 per person ($150 per family). Covered at 75% of the reasonable and customary charges for eligible services, up to an annual maximum payment of $1,500 per person for dental services ($6,000 per family) and a lifetime maximum payment of $1,500 per person for orthodontics.
Optical Coverage (For You And Your Covered Dependents)
Covered up to a maximum of $200 per person every two years for an optical examination, frames, and lenses.
Hearing Aid Coverage (For You Only)
Covered up to a maximum of $750 per person every three years for a hearing aid, and the fitting and placement of a hearing aid by a licensed audiologist.
Life Insurance Coverage (For You Only)
If you are actively working in covered employment, your life is insured for the amount of your gross earnings in the preceding calendar year rounded up to the next $100, to a maximum of $50,000.
Prescription Drug Coverage (For You And Your Covered Dependents)
Covered through a card program with a $5 copayment for generic drugs and a $10 copayment for brand name drugs for which no generic equivalents exist, and a $15 copayment for brand name drugs when a generic equivalent is available, up to a 21 day supply per prescription or refill. Maintenance prescription drugs up to a 90 day supply for chronic conditions covered through a mail order program with the same copayments.
Health Care Coverage (For Part-Time Employees)
Lifetime Maximum
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$500,000 lifetime maximum payment per person for all coverage. $50,000 lifetime maximum payment for substance abuse confinements.
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Annual Deductible
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A deductible must be incurred each calendar year for certain expenses before you begin to receive reimbursement of recognized reasonable charges. Out-Of-Network: $500 per person, applies to hospital inpatient, surgical and anesthesiology expenses only. There is no deductible when a Network provider is used or is not available.
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Basic Hospital Coverage
Lifetime Maximum
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Coverage for up to 60 days to $100,000 per confinement. In-Network or Network-Not-Available: Covered at 100%. Out-Of-Network: Subject to annual deductible, covered at 70%.
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Mental Illness and Substance Abuse Confinement
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Coverage for up to 30 hospital inpatient days for mental illness and 30 hospital inpatient days for substance abuse per 12 month period. Substance abuse subject to $50,000 lifetime maximum payment. In-Network or Network-Not-Available: Covered at 100%. Out-Of-Network: Subject to annual deductible, covered at 70%.
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Alternatives to Hospital Inpatient
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Coverage for an Ambulatory Surgical Center, Skilled Nursing or Acute Rehabilitation Facility, Home Health Care, Birthing Center or Hospice. In-Network or Network-Not-Available: Covered at 100%. Out-Of-Network: Subject to annual deductible, covered at 70%.
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Hospital Oupatient
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Coverage for use of an emergency room, operating room, and ancillary services, but only when surgery is performed. In-Network, Network-Not-Available, or Out-Of-Network: Covered up to $15 toward the cost of an emergency room or operating room, and $15 for ancillary services.
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Other Covered Services
Surgery and Anesthesiology
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Covered according to a schedule, subject to the annual deductible. In-Network: Covered at 85% of Network schedule. Out-Of-Network: Covered at 70% of Network schedule. Network-Not-Available: Covered at 80% of recognized reasonable charges.
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Diagnostic X-Ray and Laboratory Testing
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Covered up to specified dollar limit, no deductible. In-Network, Network-Not-Available, or Out-Of-Network: Covered up to $125 per calendar year.
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Weekly Disability Income Coverage (For You Only)
If you are unable to work because of an injury, illness or pregnancy, you are covered for weekly disability income. You can receive from $26 to $200 a week for up to 26 weeks for illness and 26 weeks for injury in a 12 month period.
Life Insurance (For You Only)
If you are actively working in covered employment, your life is insured for the amount of your gross earnings in the preceding calendar year to a maximum of $25,000.
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