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Health Fund

Paying for Your Care

Costs for your health care coverage are shared by both you and the Fund.

Eligible Expenses

"Eligible expenses" are the portion of expenses that the Fund says are covered for services that are covered by the Fund (i.e. for which it provides benefits).

Calendar-Year Deductible

A "calendar-year deductible" is the portion of eligible expenses you are responsible for paying each calendar year before the Fund begins to pay certain benefits.  Exceptions include prescription drug benefits, preventive and wellness benefits, many of which require copaysA fixed dollar amount you pay for an eligible expense at the time the service is provided. but no deductibles. Deductibles apply to all plans except when you receive services from TIHN.

Here is the breakdown on deductibles:

  • Individual deductible — Each covered person pays a specific amount each calendar year toward eligible expenses before the Fund begins paying a portion of those expenses.
  • Family deductible — If you cover your dependents, any medical expense that count toward an individual's deductible automatically counts toward the family deductible. Once three or more covered persons have met the combined deductible maximum, all enrolled family members are considered to have met their deductibles for the
    calendar year, and benefits will be paid accordingly.
  • Multiple family member accident — If two or more covered family members are injured in the same accident, only one individual deductible for all family members involved will be applied to the eligible expenses resulting from the accident. The deductible will be applied only to those accident-related medical expenses incurred during the calendar year in which the accident occurs.
  • Deductible carryover — This is a special provision that applies to every covered family member. It allows you to carry over eligible expenses that were applied to your deductible from one year to the next under certain circumstances. Any portion of your calendar-year deductible satisfied in the fourth quarter (i.e., October, November and December) of each year will be carried over and applied to the next calendar-year deductible.

A copayment, or "copay", is a fixed-dollar amount that you pay for an eligible expense at the time the service is provided. Some network services require a copay for each visit or service. After you pay the copay and any applicable coinsurance, the Fund pays the rest of your cost of care, up to certain maximums and limitations. Copays are required for specific benefits for all plans. Copays do not count toward your out-of-pocket maximums or deductible.


Coinsurance" is the percentage of eligible expenses that you and the Fund must pay after the calendar-year deductible has been met and after any copayment.


Check out the Summary Of Benefits for specific individual and family deductible amounts, as well as for specific copay and coinsurance amounts.

Separate copays apply to:

Note: If you're subsequently admitted to the hospital, the emergency room copay will be waived; however, you will have to pay the hospital admission copay.

Contracted Rates (Network Services)

"Contracted rates," are the rates that have been negotiated between the networks and their network providers. These rates apply only to network services. When you use a network provider, the provider should not "balance bill" or charge more than the negotiated fee. You are responsible for the non-covered expenses, any copays, the deductible and coinsurance amount. You are not responsible for the amount over the contracted rate, even if the provider bills a higher amount.

Reasonable and Customary (R&C) Limits (Non-Network Services)

Anthem Blue Cross negotiates rates with doctors and other health care providers to help you save money. We refer to these providers as being "network."

The Fund also pays for services from providers who are not in our network. Many of those plans pay for non-network services based on what is called the "reasonable," "usual and customary" or "prevailing" charge. Here is how we figure out those charges:

We receive information from a not-for-profit company formed to create an independent database not owned by any health insurer. Health plans send this independent company copies of claims for services received from providers. The claims include the date and place of the service, the procedure code, and the provider's charge. This claim information is combined into databases that show the amount providers generally charge for just about any service in any zip code.

"Reasonable and Customary (R&C) limits" are the maximum dollar amount of a charge that a plan will consider (prior to application of a deductible, coinsurance or maximum) when determining benefits payable by the Fund. Currently, the Fund's determination of what is reasonable and customary is based on 80% of what providers in your geographic area charge (as determined by the Fund, in its sole discretion) for similar services or supplies. (A "geographic area" is an area grouped by several ZIP Codes.) Any amount above the R&C limit is not considered an eligible expense. R&C limits apply anytime you see a non-network provider. If you use a non-network provider, you are responsible for paying any amount over the R&C limit.

If you are contemplating incurring a major medical expense, you may want to find out whether your non-network provider's charges fall within R&C limits for that service. Before you receive care, call the Administrative Office for assistance. R&C limits are re-evaluated and changed periodically.

Out-of-Pocket Maximum

The "out-of-pocket maximum" is the total amount of coinsurance you pay for eligible expenses during the year before the PPO and Low Cost plans begin paying 100% of most eligible expenses for the rest of the year. A new out-of-pocket maximum begins each calendar year. If you reach your out-of-pocket maximum, the plan begins paying 100% coinsurance of eligible expenses. Also keep in mind that eligible network and non-network expenses count toward the out-of-pocket maximum. (See the Summary of Benefits for the separate out-of-pocket maximums.)

Even if you reach the out-of-pocket maximum, you must still pay copays for:

  • Prescription drugs, hospital admissions, emergency room and facility visits under the PPO Plan;
  • Hospital admissions, emergency room and facility visits under the Low Option Plan; and
  • The Industry Health Network (TIHN)


Check out the Summary Of Benefits for specific out-of-pocket maximum amounts.

Some Certified Retirees who are Medicare-eligible and their Medicare-eligible dependents, spouses (opposite and same-sex) or Same-Sex Domestic Partners have lower out-of-pocket maximums than do Active Participants. (See the Summary Of Benefits for more information.)


The out-of-pocket maximum doesn't include any expenses related to Preventive Care Services, Wellness or Prescription Drug benefits.

Lifetime Maximum Benefit

The "lifetime maximum benefit" is the maximum medical benefit payable for a covered person throughout his/her lifetime. Effective January 1, 2011, the Fund's lifetime maximum benefit has been eliminated for all coverage options (PPO Plan and Low Option Plan, regardless of whether coverage is provided on an in-network or out-of-network basis) under the Health Plan.

Annual Dollar Limits:

In accordance with applicable law, none of the annual dollar limits set forth in this SPD shall apply to "essential health benefits" as such term is defined under Section 1302(b) of the Affordable Care Act. The law defines "essential health benefits" to include, at a minimum, items and services covered within certain categories, including emergency services, hospitalization, prescription drugs, rehabilitative and habilitative services and devices, and laboratory services, but currently provides little further information. Accordingly, a determination as to whether a benefit constitutes an "essential health benefit" will be based on a good faith interpretation by the Fund Administrator on the guidance available as of the date on which the determination is made. Additional information regarding the specific application of these rules may be furnished in a future communication as regulatory and other guidance governing the law is issued by the government.