The Catastrophe Major Medical Insurance Plan, endorsed by NYSUT Member Benefits Trust, is designed to help pay the catastrophic bills that can push expenses beyond what basic health insurance allows. It provides coverage for extraordinary medical expenses not covered by hospitalization, an HMO or major medical insurance, including Medicare.

For this reason, the plan includes a $25,000 deductible. Eligible medical expenses paid within a 36-month period by basic health insurance, as well as those paid out of pocket, count toward the deductible. Once the deductible is met, the plan provides up to 100 percent coverage of the plan’s reasonable and customary eligible expenses, up to $2 million in benefits for up to five full years from the date the first eligible expense was incurred toward the deductible.

People often inquire about the “reasonable and customary” terminology. Reasonable and customary means the usual charge for a certain procedure or service performed by medical providers in your area. For example, if a doctor charges $3,000 for a surgical procedure and a member’s basic medical plan reimburses $2,400, chances are that the entire $3,000 will be considered reasonable and customary and will count toward the plan’s deductible. However, if a doctor charges $5,000 for a surgery for which most doctors charge $3,000, only the portion that is considered reasonable and customary by a member’s basic medical plan will count toward this plan’s deductible.

The catastrophe plan’s coverage includes some nursing home and home health care benefits once the $25,000 deductible has been met. It provides up to $500 per week for convalescent or custodial care received in a nursing home, for up to three years ($80,000 lifetime maximum benefit). It also offers coverage for up to 300 visits per year for part-time or intermittent home health care for home health care aide services (maximum four hours per visit).

Bargaining unit members who are eligible for payroll deduction of NYSUT Member Benefits Trust-endorsed benefits can use this payment option to save 10 percent on the cost of the Catastrophe Major Medical Plan’s premiums. Retiree members can save 10 percent on the premiums by using pension deduction.

For more information, contact Member Benefits at (800) 626-8101, e-mail at benefits@nysutmail.org or visit the Web at www.memberbenefits.nysut.org.

For information about contractual expense reimbursement/endorsement arrangements with providers of endorsed programs, please contact NYSUT Member Benefits Trust or refer to your NYSUT Member Benefits Trust Summary Plan Description.