The Catastrophic Stop-Loss benefit provides for reimbursement of out-of-pocket costs not paid by the member’s basic health plan. Deductibles and co-insurance charges from the primary carrier are included in this benefit, as are charges for using non-participating providers. This unique benefit provides a safety net for our members and relieves them of a major financial burden, should they experience a catastrophic illness. Please contact the Fund office if you have any questions regarding this benefit.
Members and/or Dependents enrolled in HMOs: We understand that sometimes you may have out-of-pocket expenses for covered services not fully reimbursed by your HMO. But worry not!
Our Catastrophic Stop-Loss Benefit is designed to step in and cover 80% of these expenses after you meet a $1,000 deductible. Once the CSA Retiree Welfare Fund has reimbursed $1,000, our coverage increases to 100% up to an annual maximum of $50,000. That’s our commitment to ensuring you receive the care you need without breaking the bank. And don’t forget, the lifetime benefit is an impressive $250,000 per person.
Non-Medicare Eligible members and/or Dependents Enrolled in Emblem Health GHI: For those using doctors outside the GHI program and facing out-of-pocket expenses, we’ve got your back! Once your expenses exceed $1,000 during a calendar year for covered services, we’ll step in with 80% reimbursement until we’ve covered $1,000. From there, our coverage jumps to 100%, with an annual maximum benefit of $50,000. We consider all deductibles and co-insurance charges applied by GHI, Blue Cross, and the CSA Retiree Welfare Fund (excluding hospital charges other than the $300 per admission deductible) to make sure you get the support you deserve. And remember, you have a lifetime benefit of $250,000 per person.
Medicare Eligible members and/or Dependents Enrolled in Emblem Health GHI: Your well-being is our top priority, and that’s why we offer the same great benefit coverage as described above. The only difference is that we’ll base our reimbursement of expenses exceeding the $1,000 annual deductible on Medicare allowable charges. This way, you can be confident in our support, knowing that charges beyond Medicare guidelines will not be considered. This benefit only applies if the provider has opted out of Medicare.
We’re continuously improving our offerings to cater to your needs. For medical services provided by providers who opted out of Medicare, our Catastrophic Medical benefit will kick in. Rest assured, we’ll cover these services based on Medicare rates or 50% of the 50th percentile of Medicare allowable charges.
Supplemental Benefits
Discover the additional coverage provided by the CSA supplemental medical program, offering essential services not included or fully covered by the City health plan for retirees under 65 or the combined Medicare and supplemental City coverage for retirees over 65. The benefits are reimbursed at 80% of the approved charge, once a $100 per person deductible is met, to a maximum of $5,000 per person per year. There are special exceptions to this guideline, and members are advised to consult their CSA Retiree Welfare Fund Benefits Booklet or call the Fund Office for specific illustrations.
- Reimbursement for Emergency Ambulance Services: We’ll cover the expenses not fully reimbursed by the City Basic Health Plan or Medicare for emergency ambulance services.
- Non-Emergency Ambulance/Ambulette Reimbursement: If you require non-emergency ambulance/ambulette service due to medical necessity, we can cover the costs when public transportation options aren’t feasible. A statement from your treating physician is necessary for eligibility, and pre-approval by the CSA Retiree Welfare Fund is required.
- Orthopedic Devices for Feet: Necessary casts, splints, orthopedic, or orthotic devices for the feet (excluding orthopedic shoes) will be covered, up to $400 per pair with a maximum of two sets per patient per year.
- Wigs for Hair Loss: Patients experiencing hair loss due to chemotherapy, radiation therapy, or alopecia areata can receive coverage for necessary wigs, up to a maximum of $1,000 per year.
- Reimbursement for Surgical Stockings: We provide reimbursement up to $150 annually for surgical stockings.
- Nonpermanent or Portable Toilet Seats: One seat per 12-month period will be covered.
- Therapy Coverage: After exhausting your primary insurance benefit for therapy (physical, occupational, and mental health counseling), we offer an additional $2,000 in coverage. Please include a statement from your primary insurance carrier confirming benefit exhaustion with your claim submission.
- Co-payment Charges: If you’re enrolled in any of the City provided HMO Health Plans, such as HIP/HMO, we cover co-payment charges, such as the $25 co-pay costs for out-patient psychiatric treatments or office visits to HMO doctors or services.
- Hospital Admission Deductible: The $300 patient deductible for hospital admission (imposed by the City Health Plan) is covered, with a maximum of $750 deducted per calendar year.
- GHI/Blue Cross Expenses: For members enrolled in GHI/Blue Cross, expenses not fully reimbursed for surgery (including invasive diagnostic procedures), anesthesia, radiation, and chemotherapy costs (excluding drugs) are covered, whether in or out of a hospital.
- Private Duty Nursing: Private Duty Nursing by an RN or LPN (when an RN is not available) and certified as necessary by your doctor is covered, up to an annual maximum of $10,000.
- Home Infusion of Antibiotics: For costs associated with home infusion of antibiotics not covered by your primary health coverage (excluding the cost of medication), we’ve got you covered. Ancillary services and supplies are also included under this benefit.
- Prescription Drug Co-payments: We offer reimbursement for non-Medicare members enrolled in GHI for drugs obtained through the GHI Drug Program. Reimbursement is 80% after a $100 RX deductible is met, up to a maximum of $10,000 annually. For Medicare eligible members enrolled in GHI Senior Care with the optional rider as their Medicare D drug plan or NYC Medicare Advantage Plus plan, prescription drug co-pays are reimbursed only if they exceed the applicable TrOOP (True Out Of Pocket) amount for that year.
To file a claim for any of these services, simply submit a copy of the itemized bill, a prescription or statement of medical need from your doctor, and a copy of any action taken by the Basic Health Plan (GHI, Medicare, etc.) regarding reimbursement or denial of payment for the service.
Remember, there are three separate annual deductibles of $100 for home health aide, prescription drug co-payments, and supplemental medical benefits. Rest assured, we’re here to ensure you get the support you need!
