Note for members with the $5000, $7500 or
$10,000 deductible options:
This section does not apply to your plan. No
member coinsurance is required. Once you
meet your deductible, the Pool pays 100 percent
of covered charges (except that you pay a
percentage of covered charges for items covered
under the prescription drug plan, not
subject to the deductible.)
Remember: If you receive services from a
nonparticipating provider, you will be
responsible for paying the
provider any amounts over the covered charge.
See the examples listed in the Provide
Choices section.
Coinsurance — If you selected the $500,
$1000, or $2000 deductible: For most covered
services, you pay a percentage of covered
charges as “coinsurance” after the annual
deductible has been met. Covered charges may be
less than the billed amount. If you receive
services from a nonparticipating provider, you
will be responsible for paying the provider any
amounts over the covered charge (see the
examples listed in the Provide Choices
section), in addition to your deductible and
your percentage of the covered charge
(coinsurance).Out-of-Pocket Limit —
The total amount of deductible and coinsurance
you must pay each calendar year is called the
out-of-pocket limit. After the limit is
met, the Pool pays 100 percent of your covered
charges for the rest of the calendar year.
Remember: If you receive services from a
nonparticipating provider, you will be
responsible for paying the provider any amounts
over the covered charge, even if your
out-of-pocket limit is met.
Admission review penalty amounts, amounts over
the covered charge, non-covered expenses, and
prescription drug plan co-payments are not
applied to the out-of-pocket limit and are not
eligible for 100 percent payment under this
provision.
Family Limit — An entire family meets the
out-of-pocket limit when the total deductible
and coinsurance amounts for all family members
reaches the amount specified on the Summary of
Benefits and Plan Options. (When a member meets
the out-of-pocket limit, no more charges
incurred by that member may be used to satisfy
the family out-of-pocket limit.)
Out-of-Pocket Limit Changes — Changing
your deductible plan also affects your
out-of-pocket limit provisions. This means that
if you had met your lower out-of-pocket limit
and then you change to a higher out-of-pocket
limit, for services received as of the change
effective date, you do not receive the 100
percent payment until the increase in
out-of-pocket is met. |
