Health and Welfare Summary Plan Description
8.6 Limits on Covered Charges
- Deductible. The deductible is $150 per Covered Individual up to a maximum of $300 per family for each calendar year. This is the out-of-pocket expense for which you are responsible. Charges that are not Covered Charges and charges you pay as a coinsurance may not be used to satisfy the deductible amount. The deductible amount is subtracted from your Covered Charges and the remaining amount is multiplied by the coinsurance percentage to determine your amount payable. If charges in the last three months of a calendar year are applied toward the deductible, these charges will also be applied toward the deductible for the next calendar year. After the family deductible has been satisfied in a calendar year, no further deductible is required of that family unit for charges incurred in the remainder of that calendar year.
- Coinsurance. Except as provided otherwise in this section, after the deductible described in subsection (a) has been satisfied, Covered Charges will be paid at 80% of the contracted rate (100% for mental health and substance abuse charges) incurred in a calendar year performed by a Preferred Provider or at a Preferred Provider facility (i.e., an "in-network" provider or facility), and at 60% of Reasonable and Customary charges if not performed by a Preferred Provider or at a Preferred Provider facility (i.e., an "out-of-network" provider or facility), including for mental health and substance abuse charges. The 20% (or 40%) balance is your coinsurance, and is an out-of-pocket expense for which you are responsible. Once you or your Dependent have accumulated the maximum out-of-pocket Covered Charges described in subsection (d), the Plan will pay the balance of Covered Charges incurred during the remainder of the calendar year at 100% for services performed in-network and at 80% for services performed out-of-network. Your Covered Charges are paid only to the extent provided in this section, so you should use in-network Physicians and Hospitals if you wish to minimize your out-of-pocket cost. Any out-of-network balances you are required to pay do not count toward your out-of-pocket annual maximum under subsection (d).
- Maximum Annual Out-of-Pocket Limit. A Covered Individual shall not be required to pay in-network Covered Charges exceeding $1,500 per calendar year. Once a Covered Individual has paid $1,500 of out-of-pocket Covered Charges in a calendar year, the Plan will pay the balance of Covered Charges incurred during the remainder of the calendar year at 100% for in-network services at the PPO contract rate and at 80% the usual and customary or the reasonable and customary for out-of-network services. In no event will the out-of-pocket Covered Charges exceed the maximum amount allowable under the ACA, which for 2023 is
$18,200 per family.
- Special Rules for Out-of-Network Emergency Care. If you experience a medical condition with acute symptoms (including severe pain) such that you require emergency care to address a serious threat to your (or your unborn child's) health and/or the functioning of an organ or other part of your body, you may seek emergency care without prior authorization and without regard to whether the emergency care provider (e.g., a hospital) is in-network or out-of-network. The Plan will cover the charges of an out-of-network emergency care provider at least to the extent of what the Plan negotiated for the services with in-network providers (excluding any in-network copayment or co-insurance imposed on the Participant or Dependent) in accordance with 45 C.F.R. Section 147.138(b) and the No Surprises Act.
- Retirees. In general, the provisions of this article apply similarly to covered Retirees, except that the Plan will offset Covered Charges for a Medicare-eligible Retiree or Dependent by the amount payable by Medicare or the amount that would be payable by Medicare if the Covered Individual had enrolled in Medicare Parts A and B. (See Section 4.5(b).) Payments made pursuant to Medicare are subject to the satisfaction of any deductibles and the application of any Plan benefit maximums or coinsurance.
- Maximum Annual Plan Benefit. EThe Plan imposes no annual maximum.