Summary Plan Description

Coinsurance

After you satisfy your $200 annual deductible, you share a percentage of the remaining covered expenses with the plan. This is called coinsurance. Each person covered under the plan has his or her own $2,300 coinsurance. When you and your dependents have paid a combined coinsurance expense of $4,600 in a calendar year, no further coinsurance is required for any family member during that calendar year, except as described below. There are three coinsurance payment levels depending on (1) the type of service or supply received; (2) if the provider is network or non-network; and (3) the type of health care provider used:

  1. 90% – 10% If you use a network provider, most covered medical expenses are paid at 90 percent by the plan and at 10 percent by the patient. When the patient's coinsurance reaches $2,300 in a calendar year, benefits that would otherwise be paid at 90 percent are paid at 100 percent for the remainder of that calendar year.
  2. 80% – 20% If you use a non-network provider, most covered medical expenses are paid at 80 percent of the maximum allowable fee by the plan and at 20 percent of the maximum allowable fee by the patient. These services always require 20 percent coinsurance and these coinsurance payments do not apply toward the $2,300 or $4,600 annual coinsurance maximums. Even though there are network chiropractors, covered chiropractic expenses are also paid at 80 percent by the plan and at 20 percent by the patient. The following exceptions apply:
    • If you receive services from an emergency department at a non-network hospital for an emergency medical condition, the plan will pay covered expenses at 90 percent/100 percent of the maximum allowable fee and coinsurance expenses will apply toward the annual coinsurance and out-of-pocket maximums.
    • If you receive services that are not available from a network provider or hospital, the plan will pay covered expenses at 90 percent/100 percent of the maximum allowable fee and coinsurance expenses will apply toward the annual coinsurance and out-of-pocket maximums. You must submit proof that the services were not available from a network provider or hospital.
    • If you receive services from a non-network provider and you had no choice in the selection of the provider or knowledge that the provider was a non-network provider, the plan will pay covered expenses at 90 percent/100 percent of the maximum allowable fee and coinsurance expenses will apply toward the annual coinsurance and out-of-pocket maximums. You must submit proof that you had no choice in provider selection or knowledge of the use of a non-network provider.
  3. 50% – 50% Covered orthognathic surgery and TMJ/MPDS expenses are paid at 50 percent by the plan and at 50 percent by the patient. These services always require 50 percent coinsurance and TMJ/MPDS coinsurance payments do not apply toward the $2,300 or $4,600 annual coinsurance maximums.

Medicare-eligible retirees expenses are processed at the network level.