LOUISIANA HBPAMEDICAL BENEFIT PLAN available for download here

INTRODUCTION

The purpose of the Louisiana Horsemen’s Medical Benefit Plan is to provide to members, their employees and other eligible applicants financial assistance with eligible medical and hospital expenses.  Funding for the program is provided by Statute (R.S. 4:183) from the horsemen’s share of the pari-mutuel handle at Louisiana race tracks.

The Louisiana Horsemen’s Medical Benefit Plan is NOT an insurance program or an additional medical benefit plan.  It is a self-funded assistance program for Louisiana horsemen actively racing in the state of Louisiana.

Section 1 – ELIGIBILITY

To be eligible for Plan benefits, an applicant must be licensed by, and in good standing with the Louisiana State Racing Commission (LSRC).  In addition, an applicant must enroll in the Plan (Section 2) and satisfy the following eligibility requirements/conditions for participation:

1. OWNERS, TRAINERS, & OWNER/TRAINERS (Individually Licensed)

1. Must have started a horse at least seven (7) times at a Louisiana track, licensed by the LSRC, within the twelve (12) consecutive month period immediately preceding the filing of an application for benefits under the Plan; and

1. Must be actively racing in Louisiana at the time an application is submitted for benefits under the Plan.

      NOTE:             An applicant for Plan benefits will be deemed to be actively racing in Louisiana, if within the six (6) month period immediately preceding an application for benefits under the Plan, said applicant had:

1. OWNERS, TRAINERS, & OWNER/TRAINERS (Not Individually Licensed – e.g. Partnerships, Corporations, and other Licensed Business Entities)

To be eligible for Plan benefits under this Section, a partner, shareholder, limited partner, or other individual having ownership rights in the business entity must:

1. be individually licensed by the LSRC; AND
2. demonstrate to the Plan Administrator that he/she owns the equivalent of 100% of a race horse.  For example, a 50% interest in each of two (two) horses or a 25% interest in each of four (4) horses, would be the equivalent of 100% of a race horse; AND
3. the Partnership, Corporation, or other Licensed Business Entity:

*      must have started a horse at least fourteen (14) times at a Louisiana track, licensed by the LSRC, within the twelve (12) consecutive month period immediately preceding the filing of an application for benefits under the Plan;  and
*      must be actively racing in Louisiana at the time an application is submitted for benefits under the Plan.

NOTE:  An applicant for Plan benefits will be deemed to be actively racing in Louisiana, if within the six (6) month period immediately preceding an application for benefits under the Plan, said applicant had:
at least one (1) start and was eligible to receive benefits under the plan during the twelve(12) month period immediately preceding a six (6) month period of inactivity, if any.

1. EMPLOYEES OF MEMBERS (Assistant Trainer, Groom, Hot Walker, Exercise Rider, Pony Person, etc.)

• Must be on the payroll as a full time employee of an owner or a trainer who is eligible to receive benefits under the Plan; AND
• Must be on the work list of an owner or a trainer who is eligible to receive benefits under the Plan; AND
• Must have an affidavit completed, notarized and submitted to the LA. Horseman Medical Trust.
• Must have met the requirements of (1), (2), and (3) hereof for a period of at least thirty (30) days immediately preceding the date of which an application is submitted for benefits under the Plan.

Section 2 – ENROLLMENT

To be eligible, and to remain eligible, for Plan benefits an applicant MUST complete and file an enrollment application EVERY SIX (6) MONTHS. Enrollment periods begin on January 1st and July 1st annually, Enrollment application must be completed and signed by the applicant and, if required by the Plan Administrator, by the Owner or Trainer who is a member of the LHBPA. Application forms are available at the LHBPA main office, 1535 Gentilly Blvd., New Orleans, LA 70119, and at the LHBPA field offices which are located on the grounds of all Louisiana tracks.

Section 3 – GENERAL LIMITATIONS and/or DISQUALIFICATION

If a person who is eligible for Plan benefits (covered person) has other medical and/or hospital insurance, major medical coverage, Medicare, or ay other form of medical insurance coverage, only the portion of any medical and/or hospital expenses/charges incurred by a covered person which is in excess of the maximum amount covered by such other medical insurance or coverage will be considered as eligible expenses/charges under the provisions of this Plan.

If a covered person has any other such coverage or plan proving benefits, as a condition precedent to entitlement for benefits under this Plan, an application for benefits under such other coverage or plan must first be made and a statement or listing of the benefits provided by such other coverage or plan must be attached to any claim submitted for benefits under the Plan.

The Plan Administrator may grant an additional period of time for a claimant to provide any statement of listing of benefits provided by other coverage, provided that at the time an application for benefits is made under this Plan, and the claimant notifies the Plan Administrator that such other coverage exists.

In the event that a covered person fails, refuses, and or otherwise neglects to first make application for benefits under any other such coverage or plan, or fails, refuses and/or neglects to disclose that he/she has such other coverage or plan at the time an application for benefits is made under this Plan, any claim for benefits under the Plan shall be denied and the applicant shall be disqualified from receiving any benefits whatsoever under this plan for a period of two (2) years following the date of disqualification.

CLAIMS FOR MEDICAL EXPENSES/CHARGES SUBMITTED LATER THAN NINETY (90) DAYS FOLLOWING THE DATE FOR FIRST TREATMENT WILL BE DENIED.

All applications for and/or assignments for benefits shall be on forms provided by the Plan Administrator, Louisiana Horsemen’s Medical Benefit Plan, 1535 Gentilly Blvd., New Orleans LA 70119.

PRE-AUTHORIZATION, for the purpose of this Plan, means obtaining verification of eligibility from the Plan Administrator prior to receiving treatment.  Failure to obtain Pre-Authorization when required under the provisions of this Plan may result in the reduction and/or denial or Plan benefits.

Section 4 – MAXIMUM TOTAL BENEFIT

On or after March 9, 1999, notwithstanding anything to the contrary contained herein, the maximum total benefit payable by this Plan for all eligible charges and/or expenses on behalf of any eligible participant, shall not exceed the following during any calendar year:

$7000      for a Member
$7000      for a Spouse of a Member
$7000      for an Employee of a Member
$3000      for a Spouse of an Employee of a Member
$3000            for Dependent Children of a Member or an Employee of a Member, provided that said dependent child is under the age of eighteen (18), or is a full time student, under the age of twenty-five (25).

Section 5 – CALENDAR YEAR DEDUCTIBLES

The Calendar Year Deductible is the amount which must be deducted from all eligible expenses/charges before a covered person shall be entitled to receive benefits.

Unless specifically otherwise provided herein the Deductibles set forth in this Plan are applicable to each covered person in each calendar year and are not reimbursable as covered expenses/charges under this plan:

$0  for Member
$0 for Employee of a Member
$0 for Member Spouse
$0 for Employee Spouse
$0 for Dependent Children

Section 6 – HOSPITAL BENEFITS (IN-PATIENT)

Note:              Scheduled benefits under this section shall NOT be paid for in an in-patient surgical procedure unless:

1. the surgery is a covered procedure of this Plan; and
2. the procedure is Pre-Authorized by the Plan Administrator; AND
3. the treating physician certifies in writing to the Plan Administrator, by U.S. Mail, postage pre-paid, that because of the physical condition of the patient, or for other certifiable medical reasons, the failure to perform the surgery on an in-patient basis would likely endanger the health and/or life of the patient.

 

The Plan Administrator may waive the Pre-Authorization requirement if a covered surgical procedure is preformed on an emergency basis without Pre-Authorization, and the treating physician certifies that the procedure was preformed on an emergency basis, provided, however, that the Plan Administrator is notified within 96 hours of the procedure having been preformed.

While confined to a licensed hospital for an illness, sickness, injury, or other medical procedure which is not otherwise excluded from coverage under the terms of this Plan, the following are eligible hospital expenses/charges, after the Plan Deductible requirements are met:



1. MEMBER

Hospital Room and Board:
      up to but not exceeding twelve (12) days at no more than $150 per day.
Miscellaneous Hospital Charges:
      up to but not exceeding $600
Laboratory and Diagnostic Services, X-Rays, Physicians and Surgeons Fees:
      80% thereof but not to collectively exceed $1000.
Anesthesia Fees
      80% thereof but not to exceed $300.
Any remaining balance of all expenses/charges included in this Section hereof:
      80% thereof but not to exceed $2500 per calendar year.

1. MEMBER SPOUSE:

Hospital Room and Board:
      up to but not exceeding twelve (12) days at no more than $150 per day.
Miscellaneous Hospital Charges:
      up to but not exceeding $600
Laboratory and Diagnostic Services, X-Rays, Physicians and Surgeons Fees:
      80% thereof but not to collectively exceed $1000.
Anesthesia Fees
      80% thereof but not to exceed $300.
Any remaining balance of all expenses/charges included in this Section hereof:
      80% thereof but not to exceed $2500 per calendar year.

1. EMPLOYEE

Hospital Room and Board:
      up to but not exceeding twelve (12) days at no more than $150 per day.
Miscellaneous Hospital Charges:
      up to but not exceeding $600
Laboratory and Diagnostic Services, X-Rays, Physicians and Surgeons Fees:
      80% thereof but not to collectively exceed $1000.
Anesthesia Fees
      80% thereof but not to exceed $300.
Any remaining balance of all expenses/charges included in this Section hereof:
      80% thereof but not to exceed $2500 per calendar year.

1. SPOUSE of EMPLOYEE of Member

Hospital Room and Board:
      up to but not exceeding twelve (12) days at no more than $150 per day.
Miscellaneous Hospital Charges:
      up to but not exceeding $600
Laboratory and Diagnostic Services, X-Rays, Physicians and Surgeons Fees:
      80% thereof but not to collectively exceed $1000.
Anesthesia Fees
      80% thereof but not to exceed $300.
Any remaining balance of all expenses/charges included in this Section hereof:
      80% thereof but not to exceed $2500 per calendar year.

1. DEPENDENT CHILD

Hospital Room and Board:
      up to but not exceeding twelve (12) days at no more than $150 per day.
Miscellaneous Hospital Charges:
      up to but not exceeding $600
Laboratory and Diagnostic Services, X-Rays, Physicians and Surgeons Fees:
      80% thereof but not to collectively exceed $1000.
Anesthesia Fees
      80% thereof but not to exceed $300.
Any remaining balance of all expenses/charges included in this Section hereof:
      80% thereof but not to exceed $2000 per calendar year.

Note: Notwithstanding the provisions of Subsections A, B, and C hereof, emergency room charges for treatment of accidental bodily injury shall be eligible for reimbursement ONLY under Out Patient Benefits (Section 7 hereof).

Section 7 – OUT PATIENT BENEFITS

After the Plan deductible requirements are met, accidental bodily injury, sickness, and/or all other medical treatments and procedures not specifically covered under any other Section of the Plan, and which are not otherwise excluded from coverage under the terms of the Plan, are eligible as covered expenses/charges incurred in connection with routine doctor’s office visits are not covered under the Plan.

The following expenses/charges are specifically covered under this section.

1. MEMBER or EMPLOYEE

Emergency Out Patient Hospital Treatment:
      80% there of but not exceeding $500. For emergency treatment provided within 48 hours of an accidental bodily injury.  Work-related injuries and/or accidental bodily injury arising out of and in the course of a covered person’s employment are not covered.
Out Patient Treatment, Diagnostic X-Rays(s), Laboratory and physician Services:
      80% there of but not to exceed $1000 per calendar year.
Out Patient Surgery:
Surgeon’s Fees:       up to but not exceeding $1000.
Facility Charges:   up to but not exceeding $1000.
Anesthesia:           up to but not exceeding $400.
Any remaining balance of covered expenses/charges in this section hereof:
      80% thereof but not exceeding $1000 per calendar year.

1. MEMBER SPOUSE:

Emergency Out Patient Hospital Treatment:
      80% there of but not exceeding $500. For emergency treatment provided within 48 hours of an accidental bodily injury.  Work-related injuries and/or accidental bodily injury arising out of and in the course of a covered person’s employment are not covered.
Out Patient Treatment, Diagnostic X-Rays(s), Laboratory and physician Services:
      80% there of but not to exceed $1000 per calendar year.
Out Patient Surgery:
Surgeon’s Fees:       up to but not exceeding $1000.
Facility Charges:   up to but not exceeding $1000.
Anesthesia:           up to but not exceeding $400.
Any remaining balance of covered expenses/charges in this section hereof:
      80% thereof but not exceeding $1000 per calendar year.

1. DEPENDENT CHILD:

Emergency Out Patient Hospital Treatment:
      80% there of but not exceeding $150. For emergency treatment provided within 48 hours of an accidental bodily injury.  Work-related injuries and/or accidental bodily injury arising out of and in the course of a covered person’s employment are not covered.
Out Patient Treatment, Diagnostic X-Rays(s), Laboratory and physician Services:
      80% there of but not to exceed $450 per calendar year.
Out Patient Surgery:
Surgeon’s Fees:       up to but not exceeding $450.
Facility Charges:   up to but not exceeding $450.
Anesthesia:           up to but not exceeding $400.
Any remaining balance of covered expenses/charges in this section hereof:
      80% thereof but not exceeding $450 per calendar year.

Section 8 – MATERNITY BENEFITS

Notwithstanding any other provisions of the Plan to the contrary, and provided that the claimant is eligible under the terms of the Plan on the delivery date, a claim for maternity benefits and/or all related expenses/charges in connection therewith shall be limited to the following:

1. MEMBER or MEMBER SPOUSE

Provided that nine (9) months prior to the normal delivery date, a cover person was entitled to receive benefits under this Plan, and only after a $2000 calendar year deductible is applied, the scheduled benefit is as follows:

         Normal Delivery:
                     80% of expenses/charges related thereto but not to exceed $2000 per calendar year.

2. EMPLOYEE or EMPLOYEE SPOUSE

 

Providing that nine (9) months prior to the normal delivery date, a covered person was entitled to receive benefits under this Plan, and provided that such covered person has been continuously eligible to receive benefits under this Plan for a period of not less than 270 days prior to the delivery date and only after a $1500 calendar year deductible is applied, the scheduled benefit is as follows:
      Normal Delivery:
            80% of expenses/charges related thereto but not to exceed $1500 per calendar year.
      Miscarriage:
            80% expenses/charges related thereto but not to exceed $750 per calendar year.

Section 9 – PERSCRIPTION MEDICATIONS (Deductible Waived)

Reimbursement for prescribed medications approved by the plan shall be limited as follows:

1. MEMBER or EMPLOYEE:

80% of covered expenses/charges up to but not exceeding $2000 per calendar year (Section 5 deductible waived).

1. MEMBER SPOUSE

80% of covered expenses/charges up to but not exceeding $2000 per calendar year.

1. EMPLOYEE SPOUSE

80% of covered expenses/charges up to but not exceeding $500 per calendar year.

1. DEPENDENT CHILD

80% of covered expenses/charges up to but not exceeding $200 per calendar year.

Section 10 – DENTAL TREATMENT (Deductible Waived)

1. MEMBER:

Up to but not exceeding $1000 for extraction, fillings and x-rays per calendar year.

80% thereof but not to exceed $1200 for the cost of partial or full dentures.                       

2. EMPLOYEE:

Up to but not exceeding $600 for extraction, fillings and x-rays per calendar year.

80% thereof but not to exceed $800 for the cost of partial or full dentures.           

3. MEMBER SPOUSE:

Up to but not exceeding $1000 for extraction, fillings and x-rays per calendar year.

80% thereof but not to exceed $1200 for the cost of partial or full dentures.           

DEPENDENT CHILD IS EXCLUDED FROM COVERAGE.

Section 11 – EYEGLASSES and/or EYE EXAMINATIONS (Deductible Waived)

1. MEMBER, MEMBER SPOUSE:

Expenses/charges incurred in connection with an eye examination (refraction), lenses, contact lenses, and/or frames shall be reimbursed up to but not exceeding $225 in any twelve (12) consecutive month period.

2. EMPLOYEE, EMPLOYEE SPOUSE:

Expenses/charges incurred in connection with an eye examination (refraction), lenses, contact lenses, and/or frames shall be reimbursed up to but not exceeding $150 in any twelve (12) consecutive month period.

3. DEPENDENT CHILD

is excluded from coverage.

Section 12 – CHIROPRACTIC TREATMENT (Deductible Waived)

1. MEMBER or EMPLOYEE

Up to but not exceeding $300 for each treatment provided, however, that the maximum benefit hereunder shall not exceed $300 in any calendar year.

2. All Other Covered Persons:

Chiropractic treatment is excluded from coverage.

 

Section 13 – Retired Members’ Benefits

Notwithstanding the provision of Section 1 to the contrary, a retired member over age 65, shall be eligible to receive the benefits under this Section provided that the retired member furnishes the Plan Administrator with documentation satisfactorily demonstrating that he/she had met the plan eligibility requirements as an active member during each of the five (5) years immediately preceding his/her retirement.

Benefits under this Section are supplemental to Medicare and are limited to the following:

1. Medicare Part A Deductible: paid at 100%
2. All other eligible expenses/charges which are not paid or reimbursed by Medicare, shall be paid or reimbursed under the provision of the Plan, pursuant to the schedule of benefits available to an active member, but only up to an not exceeding 80% of the maximum allowable benefit for active member under each Section of the Plan, but only up to but not exceeding a total maximum annual benefit of $5000, for a retired member.

 

3. The RETIRED MEMBER’S SPOUSE is eligible for coverage on Dental Prescriptions, and Optical benefits only.

Section 14 – DEATH BENEFITS

1. MEMBER or EMPLOYEE

 

$750 if death occurs while covered by the Plan, and proof of death is furnished to the Plan Administrator in the form of a certified Death Certificate by the heirs and/or legal beneficiary of the deceased member or the deceased employee of a member.

At the option of the Plan Administrator, any death benefit payable hereunder may be remitted directly to the funeral home and/or undertaker providing burial services for the said deceased.

• All Other Covered Persons:

Death Benefits are excluded from coverage.

Section 15 - MISCELLANEOUS BENEFITS

1. MEMBERS and EMPLOYEES only are eligible for the following additional miscellaneous benefits

 

Ambulance Services/Charges/Fees:
            80% there of but not to exceed $600.
Hearing Aids and Exams:
            80% there of but not to exceed $500.
Artificial Limbs, Organs and Eyes:
            80% there of but not to exceed $500.
Electronic Pacemaker Equipment:
            80% there of but not to exceed $500.
Blood and Plasma:
            80% there of but not to exceed $500.
Physical Therapy:
            80% there of but not to exceed $500.
Mental Illness, Functional Nervous Disorders, Alcohol/Substance Abuse:
            80% there of but not to exceed $500.

Section 16 – EXCLUSIONS

The following medical or surgical procedures, actions, fee, prostheses, aids, services, treatments, appliances, etc., including those shown and/or set forth on the current Schedule of Exclusions maintained by the Plan Administrator, are excluded from coverage under the Plan.  A partial list of exclusions are as follows:

• Abortion
• Accidental Bodily Injury arising out of/or in the course of one’s employment
• Accidental Bodily Injury when covered by Automobile Insurance
• Cosmetic Surgery
• Equipment used in its administration
• Intention Self-Inflicted Injuries (while sane or insane)
• Liability Insurance, and/or Worker’s Compensation Insurance claims.
• Occupational Diseases
• Pre-Existing Illness or Illnesses until after the expiration of one year following the written notification thereof of the Plan Administrator
• Private Duty Nurses
• Rental or Purchase of Medical and/or surgical Equipment, Oxygen and Well Baby Care

 

For a more complete list of exclusions, contact the Plan Administrator.

 

Section 17 – MISCELLANEOUS PROVISIONS

1. The LHBPA Medical Benefit Trust shall have the right at any time, by Resolution, with or without notice, to:
• Change the classification of and/or any amount of any benefit available under the terms of the Plan; and/or
• Change the eligibility requirements for participation;
• Change any rules or regulations of the Plan; and/or
• Terminate the Plan.

 

2. The issuance of and/or the acceptance of any claim form for benefits under the Plan shall not constitute acceptance and/or acknowledgement of a covered person’s eligibility for benefits, nor shall such be interpreted and/or payments under any provisions of the Plan.
3. Each recipient of and/or applicant for benefits shall:

 

• Be deemed to have agreed to be bound by the Plan rules, provisions, schedules, regulations and/or other requirements including but not limited to its limitations and exclusions; and
• Be deemed to have accepted as final, any decision by the Plan Administrator or his/her designee, or the LHBPA Medical Benefit Trustees, with regard to eligibility, exclusions, limitations, entitlement, coverage, interpretation of the Plan’s provisions and/or payment of benefits hereunder.