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Health Fund

Getting The Most From Your Plan

The Low Option Plan is designed to give you a choice when it comes to getting medical care. The plan has additional limits on what the Fund pays in order to keep costs low. Since you pay a higher or lower coinsurance The percentage of eligible expenses you're responsible for paying. depending on whether you seek treatment from network or non-network providers, it's important to know how to reduce your costs as much as possible.

Also keep in mind that separate out-of-pocket maximumsThe maximum amount you pay in coinsurance each plan year for eligible medical expenses. apply to network providers and non-network providers.

Claim Example: Take Bobby, who enrolled in the Low Option Plan as an Extended Coverage Program participant, and Max, Bobby's Same-Sex Domestic PartnerAn individual who has submitted to the Fund an Affidavit of Domestic Partnership on a form provided by the Fund, along with supporting documentation, and who meets the criteria set forth in such Affidavit. Generally, for a partner to qualify, both the participant and his/her same-sex partner must acknowledge being in a committed relationship which has been in existence for at least six months. For more information, contact the Administrative Office.. Max has bunions and goes to a network doctor. He knows that for doctor visits, he has to pay the coinsurance The percentage of eligible expenses you're responsible for paying.. Let us assume that Max has met the individual calendar-year deductible of $750. Let us also assume that the Fund pays 70% for network services, and that Max pays 30%. If his doctor's negotiated fee is $90, Max's share of that cost is 30% of $90, or $27.

Bobby wants to see a doctor about a knee problem. He does not look for a network provider. He goes to the doctor he saw advertised in the trades who is a non-network provider. The doctor's visit sets him back $300, which he pays at the time, even though he's met his calendar-year deductible The portion of eligible expenses you are responsible for paying each calendar year before the Fund begins to pay certain benefits.. When he sends in the bill for reimbursement, the Fund pays a smaller percentage, 60%, 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, or a total of $102.

Patients Calendar-Year Deductible Physician's Charge R&C
% of R&C Charges the Fund Pays Amount
Fund Pays
Amount The Patient Pays
(goes to a
$750 $90* N/A 70% $90 x 70%
= $63
$90 x 30%
= $27
after deductible
Bobby (goes to a non-network
$750 $300 $170 60% $170 x 60%
= $102

$170 x 40%
= $68

  $300 - $170
= $130

Total: $198
after deductible

* This is the contracted rate. Otherwise, the charge would have been $250.

Bobby is responsible for paying $198, and Max has to pay just $27.

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