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Health Fund

Getting The Most From Your Plan

The PPO Plan gives you a choice when it comes to getting medical care. Depending on how you use the plan, you will pay more or less for your care. You will also spend more or less time filing claims.

What Does All This Mean If I Go To The Doctor?

If you go to a network provider:

If you go to a non-network provider:

Claim Example:  The Participant's wife, Lynn, has bronchitis and goes to a network doctor. She knows that for doctor's visits, she does not have to pay a copayA fixed dollar amount you pay for an eligible expense at the time the service is provided., but she does have to pay the coinsurance The percentage of eligible expenses you're responsible for paying.. Let us assume that Lynn has already met her individual calendar-year deductibleThe amount you must pay for covered services in a plan year before the plan begins to pay benefits. The portion of eligible expenses you're responsible for paying each calendar year before the Fund begins to pay certain benefits. of $300. Let us also assume that the Fund pays 85% of the contracted rate for network services, which makes her coinsurance 15%. The spouse's doctor sends a bill for $120, but because his contracted rateThe fee that is negotiated between the plans and their network providers. Contracted rate applies to network services only. is $90 for that service, Lynn's share of that cost is 15% of $90, or $13.50.

The Participant, Jimmy needs to go to the doctor. Let us assume that Jimmy has already met his individual calendar-year deductible. He always lets his business manager worry about bills, so he doesn't try to find a network provider. Instead, he goes to a new doctor in Beverly Hills. The doctor charges $300 for the visit and Jimmy has to pay it up-front. The Fund will pay a percentage of R&CReasonable and Customary Charge - The fee regularly charged and received for a given service by the health care provider which doesn't exceed the general level of charges, as determined by the Fund, being made by providers of similar training and experience for treatment of a similar sickness, condition or injury in a similar geographic area. To determine an R&C charge, physicians are surveyed by region to determine what they will accept as payment for each procedure. That data is organized in percentile groups - the Fund uses the 80th percentile to determine R&C charges. charges for non-network services, and Jimmy is responsible for paying the balance. Assume that the R&C charge for that service is $170:

Patients Physician's
% Of
Amount The Fund Pays
Amount The
Fund Pays
Lynn Pays
(goes to a network provider)
$90 x 85%
= $76.50
$90 x 15%
= $13.50
(deductible was
already met)
(goes to a non-network
$170 x 70%
= $119

$170 x 30%
= $51
(deductible was
already met)

* The Fund's reimbursement for network providers is considered at 85% of the allowable charges/contract rate.
** The Fund's reimbursement for non-network providers is considered at 70% of the Reasonable and Customary charges.

Jimmy is responsible for $51.

Note: Costs cited in this example are for illustrative purposes only. Your own costs may be different.