How the Choices Medical Plan Works
Out-of-Network Providers – Providers who do not have a contract with the Plan claim’s administrator. You pay 35% of the allowed amount (after a separate deductible) for services received Out-of-Network. Out-of-Network providers can also balance bill you for any difference between their billed charge and the allowed amount.
Plan members receive medical services from a health care provider. If the provider is In-Network, the provider will submit a claim for the member. The Medical Plan claim’s administrator processes the claim and sends an Explanation of Benefits (EOB) to the member and the provider, showing the member’s payment responsibilities (deductible, copayments, and/or coinsurance costs). The Plan then pays the remaining allowed amount. The provider will not bill the member the difference between the billed charge and the allowed amount.
Emergency Services – Emergency services are covered everywhere. However, Out-of-Network providers may balance bill the difference between the allowed amount and the billed charge.
If the provider is Out-of-Network, the member must verify if the provider will submit the claim or if the member must submit the claim. The Medical Plan claim’s administrator processes the claim and sends an EOB to the member showing the member’s payment responsibilities (deductible, coinsurance, and any difference between the billed charge and the allowed amount (balance billing)).
Deductible – The amount you pay each benefit plan year before the Plan begins to pay. Copayment - A fixed dollar amount you pay for a covered service that a member is responsible for paying. The Medical Plan pays the remaining allowed amount. Coinsurance – A percentage of the allowed amount for covered charges you pay, after paying any applicable deductible.
Definition of Terms In-Network Providers – Providers who have contracted with the Plan claim’s administrator to manage and deliver care at agreed upon prices. Members may self-refer to In-Network providers and specialists. There is a cost savings for services received In-Network. You pay a $25 copayment for Primary Care Physician (PCP) visits and a $40 copayment for Specialty provider visits to In-Network providers (no deductible) and 25% coinsurance (after deductible) for most In-Network hospital/ facility services.
Out-of-Pocket Maximum - The maximum amount of money you pay toward the cost of covered health care services. Out-of-Pocket expenses include deductibles, copayments, and coinsurance.
Important Verify the network status of your providers. This is an integral cost savings component of each of your plan
choices.
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