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4.1.2 HealthLink Open Access III and Out of Area Percentage Payable |
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Medical Benefits are payable at the following rates if a Covered Person incurs Covered Charges during a calendar year after satisfying the applicable Deductible requirement for that calendar year.
HMO. HMO charges are payable at 100% after you pay the applicable deductible and Co-Pay shown in the Schedule of Benefits (Section 4.1).
PPO. Except for Physician’s office visits, PPO eligible charges are payable at 90% until the out-of-pocket maximum has been met; 100% is payable thereafter for eligible charges incurred for the balance of the calendar year.
Charges for office visits with a PPO Physician are payable at the rate of 100% after you pay the applicable Co Pay per visit. Office visit charges are not subject to a deductible. The Co Pay and 100% payment apply to the Physician's charge for the office visit itself, not to charges for other services performed at the time of the office visit. Charges made by PPO Physicians for other services, such as injections, x rays, and laboratory tests are subject to the Outpatient Deductible and are payable at the rate of 90%. The Co-pay is not applied to your deductible but it is applied to your out of pocket maximum.
Non-Network. Non-Network covered eligible charges are payable at 50% of the first $5,000 in excess of the deductible; 80% of the next $11,500 and 100% thereafter for eligible charges incurred during the remainder of the calendar year.
Charges in connection with (a) Emergency (see definition of “Emergency” on page 119) confinement in Non-Network Hospitals and (b) confinements in Non-Network Hospitals, when the required care is not available at an HMO or PPO Hospital are paid at PPO rates until the patient can be transferred to an HMO or PPO Hospital.
Non-Network Physicians’ charges required for Emergency care (see page 119) are paid at the PPO level of benefits until such time as care by a network physician can be obtained without jeopardizing the patient's health.
Emergency use of Non-Network ambulance transportation is also covered at the PPO benefit level.
Non-Network ambulance, radiologists, pathologists and anesthesiologists are covered at PPO rates if the patient is admitted to an HMO or PPO Hospital by an HMO or PPO Physician.
Out-of-Area covered eligible charges are payable at 80% of the first $10,000 in excess of the deductible; 90% of the next $10,000; and 100% thereafter for eligible charges incurred during the remainder of the calendar year.
Important Note: It is the intent of this provision that no Participant or Dependent will be “out of pocket” more than $2,000 (for HMO and PPO providers combined, including Co-Pays), $5,700 (for Non-Network providers) or $3,800 (for Out-of-Area providers) in covered charges in a calendar year for any individual and no more than $4,000 (for HMO and PPO providers combined), $11,400 (for Non-Network providers) or $7,600 (for Out-of-Area providers) in covered charges during a calendar year for all covered family members combined.
Certain expenses do not count toward the out of pocket maximum:
- Those covered charges with special limitations, which are specifically noted in Section 4.3.4, beginning on page 72;
- Mental Illness and Chemical Dependency charges - Section 4.3.5, beginning on page 81.
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TABLE OF CONTENTS |
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St. Louis Graphic Arts Joint Health & Welfare Fund
14323 South Outer Forty Rd. - Suite S106
Chesterfield, Missouri 63017 |
Fund Office: (314) 878-1579
twesthues@slgahw.org
Fax: (314) 275-2640 |
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