Laborers District Council

Claims address for Laborer claims:

Amalgamated Employee Benefits Administrators

Payor ID – 13550

P.O. Box 5442 White Plains, NY 10602

(800) 220-5261 EXT 28617

GOLD PLAN

Common Medical Event	Services You May Need	Your Cost If You Use a Network Provider	What Will be Covered if You Use an Out of Network Provider	Limitations & Exceptions
If you have mental health, behavioral health, or substance abuse needs	Mental/Behavioral health outpatient services	$20 copay per visit	70% of allowance, after deductible **	Out of pocket maximum
	Mental/Behavioral health partial services	$20 copay per day ***	70% of allowance, after deductible **	Out of pocket maximum
	Mental/Behavioral health inpatient services	$150 copay per day for the first (5) days * (copay waived for first admission)	70% of allowance, after deductible **	$750 maximum copay per individual per stay
	Mental/Behavioral health inpatient miscellaneous facility charges	Included in room and board facility charges	70% of allowance, after deductible **	Out of pocket maximum
	Substance use disorder outpatient services	$20 copay per visit	70% of allowance, after deductible **	Out of pocket maximum
	Substance use disorder partial services	$20 copay per day ***	70% of allowance, after deductible **	Out of pocket maximum
	Substance use disorder inpatient services	$150 copay per day for the first (5) days * (copay waived for first admission)	70% of allowance, after deductible **	$750 maximum copay per individual per stay
	Substance use disorder miscellaneous facility charges	Included in room and board facility charges	70% of allowance, after deductible **	Out of pocket maximum

* Inpatient copays are waived for the first admission, but applied to subsequent admissions thereafter.

** 70% of allowance refers to 70% of ATAP’s usual and customary charges. As a member, if the provider does not accept this as full payment, you can be balance billed anything above this and what you pay will not count toward your out of pocket maximum.

*** If a member is stepped down into a partial program from an inpatient program as part of a continuum of care, the copays will be waived for the course of the partial treatment. If a member admits directly into partial, the copay will apply.

Important Questions	Answers	Why this Matters:
What is the plan year?	May 1 – April 30	The plan year impacts the way your benefit plan will cover your treatment costs.
What is the overall deductible?	For each plan year (May 1- April 30): Network: Individual $0/ Family $0. Out of Network: Individual $500/ Family $1500	You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use.
What is the overall lifetime maximum?	For both network and out of network there is no lifetime maximum; it is unlimited.	The lifetime maximum refers to the total amount of money you can put out over the time you are covered by these benefits.
Is there an out of pocket maximum on my expenses?	Yes. Network: Individual $3000 / Family $9000. Out of Network: Not applicable	The out of pocket maximum is the most you could pay during a coverage period for your share of the cost of covered services. This limit helps you plan for health care expenses. For in network charges, only copays that you pay will be applied to your out of pocket maximum. For out of network charges, there is no out of pocket maximum.
Is there a limit on the number of hospital days covered by this plan?	Network: unlimited Out of network: 70 days per plan year	The number of out of network days allowed by this plan is a maximum of 70 per plan year. This means there is only out of network coverage for 70 days or less per plan year. Additional days will not be covered by this plan.
Does this plan use a network of providers?	Yes. For a list of network providers, see www.alliedtrades-online.com or call 1-800-258-6376	If you use an in network provider, this plan will pay some or all of the costs of covered services. Be aware, your in network doctor or hospital may use an out of network provider for some services. Plans use the term in network, preferred, or participating for providers in the network.
Do I need authorization/precertification to see a Mental/Behavioral health or Substance use provider?	Yes	Authorization is required for all Mental/Behavioral health and Substance use treatment services. Authorization can be obtained by calling ATAP at 1-800-258-6376. (Typically, the provider calls for this information).

Provider Frequently Asked Questions	Answers	Additional Information
What is the effective date of the policy?	SPDs are effective the 1st of each year & benefits are based on a calendar year	N/A
Is there any pre-existing?	No	N/A
Are the mental health and substance abuse benefits combined?	No	N/A
Is accreditation required?	Yes	Both state license and JACHO accreditation are required
Are prescriptions covered by this plan?	No	Prescription medications are covered by the client’s prescription plan
Do intensive outpatient programs and partial hospitalization programs come from the inpatient or outpatient benefit?	Outpatient	N/A
What type of plan is this (PPO, HMO, etc.)?	Self funded	N/A
Are all levels of care authorized based on medical necessity?	Yes	N/A
Where do providers send claims?	Claims address will be provided when pre-certification is requested	Eligibility and potential benefit term date will also be explained at this time. Provider can call 800-258-6376 at the time of pre-certification to obtain this information
Is there an electronic payer ID?	Not at this time	N/A
Are there any limitations on this policy?	Yes	See above SPD for information about deductibles, out-of-pocket maximums, and other benefit limitations

SILVER PLAN

Common Medical Event	Services You May Need	Your Cost If You Use a Network Provider	What Will be Covered if You Use an Out of Network Provider	Limitations & Exceptions
If you have mental health, behavioral health, or substance abuse needs	Mental/Behavioral health outpatient services	$30 copay per visit	70% of allowance, after deductible **	Out of pocket maximum
	Mental/Behavioral health partial services	$30 copay per day ***	70% of allowance, after deductible **	Out of pocket maximum
	Mental/Behavioral health inpatient services	$150 copay per day for the first (5) days * (copay waived for first admission)	70% of allowance, after deductible **	$750 maximum copay per individual per stay
	Mental/Behavioral health inpatient miscellaneous facility charges	Included in room and board facility charges	70% of allowance, after deductible **	Out of pocket maximum
	Substance use disorder outpatient services	$30 copay per visit	70% of allowance, after deductible **	Out of pocket maximum
	Substance use disorder partial services	$30 copay per day ***	70% of allowance, after deductible **	Out of pocket maximum
	Substance use disorder inpatient services	$150 copay per day for the first (5) days * (copay waived for first admission)	70% of allowance, after deductible **	$750 maximum copay per individual per stay
	Substance use disorder miscellaneous facility charges	Included in room and board facility charges	70% of allowance, after deductible **	Out of pocket maximum

* Inpatient copays are waived for the first admission, but applied to subsequent admissions thereafter.

Important Questions	Answers	Why this Matters:
What is the plan year?	May 1 – April 30	The plan year impacts the way your benefit plan will cover your treatment costs.
What is the overall deductible?	For each plan year (May 1- April 30): Network: Individual $0/ Family $0. Out of Network: Individual $500/ Family $1500	You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use.
What is the overall lifetime maximum?	For both network and out of network there is no lifetime maximum; it is unlimited.	The lifetime maximum refers to the total amount of money you can put out over the time you are covered by these benefits.
Is there an out of pocket maximum on my expenses?	Yes. Network: Not applicable Out of Network: $3000 / Family $9000	The out of pocket maximum is the most you could pay during a coverage period for your share of the cost of covered services. This limit helps you plan for health care expenses. For out of network charges, boththe deductible and your 30% coinsurance (of ATAP’s usual and customary charges) will be applied to your out of pocket maximum.
Is there a limit on the number of hospital days covered by this plan?	Network: unlimited Out of network: 70 days	The number of out of network days allowed by this plan is a maximum of 70 per plan year. This means there is only out of network coverage for 70 days or less per plan year. Additional days will not be covered by this plan.
Does this plan use a network of providers?	Yes. For a list of network providers, see www.alliedtrades-online.com or call 1-800-258-6376	If you use an in network provider, this plan will pay some or all of the costs of covered services. Be aware, your in network doctor or hospital may use an out of network provider for some services. Plans use the term in network, preferred, or participating for providers in the network.
Do I need authorization/precertification to see a Mental/Behavioral health or Substance use provider?	Yes	Authorization is required for all Mental/Behavioral health and Substance use treatment services. Authorization can be obtained by calling ATAP at 1-800-258-6376. (Typically, the provider calls for this information).

Provider Frequently Asked Questions	Answers	Additional Information
What is the effective date of the policy?	SPDs are effective the 1st of each year & benefits are based on a calendar year	N/A
Is there any pre-existing?	No	N/A
Are the mental health and substance abuse benefits combined?	No	N/A
Is accreditation required?	Yes	Both state license and JACHO accreditation are required
Are prescriptions covered by this plan?	No	Prescription medications are covered by the client’s prescription plan
Do intensive outpatient programs and partial hospitalization programs come from the inpatient or outpatient benefit?	Outpatient	N/A
What type of plan is this (PPO, HMO, etc.)?	Self funded	N/A
Are all levels of care authorized based on medical necessity?	Yes	N/A
Where do providers send claims?	Claims address will be provided when pre-certification is requested	Eligibility and potential benefit term date will also be explained at this time. Provider can call 800-258-6376 at the time of pre-certification to obtain this information
Is there an electronic payer ID?	Not at this time	N/A
Are there any limitations on this policy?	Yes	See above SPD for information about deductibles, out-of-pocket maximums, and other benefit limitations

BRONZE PLAN

Common Medical Event	Services You May Need	Your Cost If You Use a Network Provider	What Will be Covered if You Use an Out of Network Provider	Limitations & Exceptions
If you have mental health, behavioral health, or substance abuse needs	Mental/Behavioral health outpatient services	$30 copay per visit ***	No out of network available on this plan	Out of pocket maximum
	Mental/Behavioral health partial services	$30 copay per day **	No out of network available on this plan	Out of pocket maximum
	Mental/Behavioral health inpatient services	$150 copay per day for the first (5) days * (copay waived for first admission)	No out of network available on this plan	$750 maximum copay per individual per stay
	Mental/Behavioral health inpatient miscellaneous facility charges	Included in room and board facility charges	No out of network available on this plan	Out of pocket maximum
	Substance use disorder outpatient services	$30 copay per visit ***	No out of network available on this plan	Out of pocket maximum
	Substance use disorder partial services	$30 copay per day **	No out of network available on this plan	Out of pocket maximum
	Substance use disorder inpatient services	$150 copay per day for the first (5) days * (copay waived for first admission)	No out of network available on this plan	$750 maximum copay per individual per stay
	Substance use disorder miscellaneous facility charges	Included in room and board facility charges	No out of network available on this plan	Out of pocket maximum

* Inpatient copays are waived for the first admission, but applied to subsequent admissions thereafter.

** If a member is stepped down into a partial program from an inpatient program as part of a continuum of care, the copays will be waived for the course of the partial treatment. If a member admits directly into partial, the copay will apply.

*** Outpatient services are limited to (4) visits per plan year. Partial treatment is also considered an outpatient service.

Important Questions	Answers	Why this Matters:
What is the plan year?	May 1 – April 30	The plan year impacts the way your benefit plan will cover your treatment costs.
What is the overall lifetime maximum?	There is no overall lifetime maximum on this plan; it is unlimited.	The lifetime maximum refers to the total amount of money you can put out over the time you are covered by these benefits.
Is there an out of pocket maximum on my expenses?	No	The out of pocket maximum is the most you could pay during a coverage period for your share of the cost of covered services. For this plan there is no out of pocket maximum.
Is there a limit on the number of hospital days covered by this plan?	Network: unlimited	There are no day limits on this plan.
Does this plan use a network of providers?	Yes. For a list of network providers, see www.alliedtrades-online.com or call 1-800-258-6376	If you use an in network provider, this plan will pay some or all of the costs of covered services. Be aware, your in network doctor or hospital may use an out of network provider for some services. Plans use the term in network, preferred, or participating for providers in the network. There are no out of network benefits available on this plan.
Do I need authorization/precertification to see a Mental/Behavioral health or Substance use provider?	Yes	Authorization is required for all Mental/Behavioral health and Substance use treatment services. Authorization can be obtained by calling ATAP at 1-800-258-6376. (Typically, the provider calls for this information).
Are there any limits on the number of services I can receive on this plan?	Yes	On this plan, a total of four outpatient services are allowed per plan year. This would include outpatient services, intensive outpatient services, and partial services. Also, inpatient treatments are limited to two admissions per plan year.

Provider Frequently Asked Questions	Answers	Additional Information
What is the effective date of the policy?	SPDs are effective the 1st of each year & benefits are based on a calendar year	N/A
Is there any pre-existing?	No	N/A
Are the mental health and substance abuse benefits combined?	No	N/A
Is accreditation required?	Yes	Both state license and JACHO accreditation are required
Are prescriptions covered by this plan?	No	Prescription medications are covered by the client’s prescription plan
Do intensive outpatient programs and partial hospitalization programs come from the inpatient or outpatient benefit?	Outpatient	N/A
What type of plan is this (PPO, HMO, etc.)?	Self funded	N/A
Are all levels of care authorized based on medical necessity?	Yes	N/A
Where do providers send claims?	Claims address will be provided when pre-certification is requested	Eligibility and potential benefit term date will also be explained at this time. Provider can call 800-258-6376 at the time of pre-certification to obtain this information
Is there an electronic payer ID?	Not at this time	N/A
Are there any limitations on this policy?	Yes	See above SPD for information about deductibles, out-of-pocket maximums, and other benefit limitations

Header Info

Allied Trades Assistance Program