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EEOICPA Medical Benefits

EEOICPA Medical Benefits

EEOICPA Medical Benefits are the least understood benefits under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA). This is the one area that we as a premier in-home health care provider get asked the most questions. Loyal Service Agency Inc. employs an EEOICPA Liaison who specializes in understanding the EEOICPA and your benefits. For further information about special circumstances or individual cases, please contact us today and ask for our EEOICPA Liaison.



Ancilary Medical BenefitsEEOICPA Medical Benefits Overview

As a qualified claimant under the EEOICPA, administered by the Department of Labor (DOL), you are entitled to medical benefits to cover the reasonable cost of treatment for your accepted condition(s). EEOICPA medical benefits for covered illnesses include reasonable and customary medical care, treatment, services, drugs prescribed by a physician, medical equipment, supplies, in-home health care, home & vehicle modifications, and travel directly associated with the treatment of a covered illness.



Targeted Case ManagementGeneral Medical Services

EEOICPA Medical Benefits are awarded for accepted conditions on your claim. The medical condition(s) accepted on your claim are covered for medical benefits from the day that you filed your claim for those conditions accepted. EEOICPA Medical Benefits pays for usual and customary treatment, services, appliances, and supplies prescribed or recommended by a qualified physician for that condition which is likely to cure, give relief, or reduce the degree or the period of that condition. You do not pay a deductible or a co-payment for services rendered by an enrolled provider.


white_spaceReasonable and customary medical service for your covered condition(s) includes the following:


-Doctor’s Office Visits
-Medical Treatment
-In-patient hospital charges
-Out-patient hospital charges
white_space-Emergency Room Visits
-Diagnostic Laboratory and Radiological testing
-Ambulance Services
-Non-emergent medical transport
-Prescription Drugs



skilled nursing careMedical Services Requiring Prior Authorization

Most medical services do not require you to obtain prior authorization from your EEOICPA Claims Examiner. Typically you will visit your enrolled provider and receive your medical services after presenting your EEOICPA medical benefits card. This will allow your provider to bill the EEOICPA directly, However, there are some medical services you may need but will require that you obtain authorization from your EEOICPA Claims Examiner before you incur the expense to allow your enrolled provider to bill the EEOICPA directly.


white_spaceHere are some medical services that requires you to obtain prior authorization:


-Overnight Travel
-Companion Travel
-Specialized Medical Equipment
-Durable Medical Equipment
-Any health or gym facility membership
white_space-Home exercise equipment
-Automobile Modifications
-Home Modifications
-Organ Transplants
-Stem Cell Transplants
-Medical Documentation Retrieval
-Home Health Care Services
-Nursing Home
white_space-Assisted Living Facility
-Hospice Care
-Psychiatric Treatment
-Chiropractic Treatment
-Acupuncture Treatment



Denied Medical ServicesWhat is NOT Covered by the EEOICPA

When awarded medical benefits under the EEOICPA you are only entitled to medical services for your accepted condition or conditions. This means that the only medical services for which the EEOICPA will pay, is for medical services that are usual and customary or are medically necessary for the treatment of your covered condition(s).


The following are some of the most common costs that are NOT COVERED by the EEOICPA:

white_space-Treatment of medical conditions not related to your accepted condition(s)
-Medical treatment for anyone other then yourself.
-Medicines that are not prescribed by a physician.
-Prescriptions for non-accepted conditions.
-Personal Services



Home Health CareHome Health Care

Home Health Care includes both in-home skilled nursing care, and the services of a home health aide or personal care assistant to assist you with activities of daily living, related to your covered condition(s). There are no restrictions on when you can apply for home health care once you have been accepted for medical benefits for a covered condition. However, home health care is authorized based upon the presentation of medical documentation which establishes and confirms the need for care due to your covered condition(s). We will assist you in making a claim for in-home health care services and work with your treating physician and the EEOICPA to get you the services necessary to keep you in the comfort of your home.



Durable Medical EquipmentDurable Medical Equipment & Supplies

Durable Medical Equipment or DME are items that serve a medical need for the treatment or therapy of an illness or physical condition. Durable medical equipment must serve a medical purpose and be able to withstand repeated use. Some examples of equipment that are considered DME include: oxygen concentrators, wheelchairs, walkers, and bathroom/bedroom safety equipment. We have partnered with Total Options, a premier Durable Medical Equipment provider. They will deliver your needed durable medical equipment directly to your home. Learn more about Total Options.



Travel ReimbursementTravel Reimbursement

You may be reimbursed for the cost of travel for medical treatment or to pick up prescriptions related to your covered condition(s). You will be reimbursed for mileage at the rate established by the General Services Administration (GSA). You can get the current mileage reimbursement rate here. Authorization is not required for travel that does not exceed 200 miles round trip. For your longer trips that exceed 200 miles you can obtain authorization for travel to include mileage, lodging, meals and incidental expenses (M&IE). You may also obtain authorization for a companion to accompany you on your trip if it is medically necessary. You can obtain the lodging and M&IE reimbursement rates on the GSA website here.



Consequential IllnessConsequential Illness

A consequential illness is a new and separate diagnosed medical condition. One that is specifically identified by your doctor as having developed due to your original or primary accepted condition(s). In some cases a new illness can be a consequential illness if it is being aggravated or contributed to by your original or primary accepted condition(s). Consequential illness can be claimed and covered under the EEOICPA. We can assist you in identifying and claiming consequential conditions to obtain the additional medical benefits coverage under the EEOICPA.



Reimbursement of Out of Pocket ExpensesOut of Pocket Expenses

You may request reimbursement for out of pocket expenses for medical treatment and prescriptions or other medical services for your accepted or covered condition(s). This can include expenses incurred prior to the acceptance of your claim or for services rendered by a non-enrolled provider. Reimbursement of expenses is allowed retroactive to the filingĀ  date of your claim. All claims for reimbursement are subject to the timely filing requirements of the EEOICPA. To request reimbursement for out of pocket expenses contact our EEOICPA Liaison to assist you in completing Form OWCP-915.



EEOICPA Medical Benefits CardMedical Benefits Card

Once you are awarded medical benefits under the EEOICPA, you will receive a Medical Benefits Identification Card. The card is to be presented at the time of treatment for your covered condition(s). Again, there is no co-pay or deductible expenses to be paid by you. Anytime you are awarded medical benefits for a new covered condition to include consequential illnesses, you will receive a new Medical Benefits Identification Card. Your card will contain everything needed for your medical provider to the bill the EEOICPA.



Enrolled ProviderEnrolled Providers

Medical providers to include pharmacies and specialist across the nation are enrolled with the EEOICPA. An enrolled provider is a medical provider who has signed up with the EEOICPA to bill the program directly for services rendered in relation to your covered condition(s). You can look up enrolled providers on the EEOICPA’s Medical Provider Search Tool. You will not incur any out of pocket expenses if you use an enrolled provider. However, you may receive services from an non-enrolled provider. In such cases you will be required to pay for services out of pocket then file for reimbursement.

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