Medical Benefits > How The Regular Plan Works
How The Regular Plan Works
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The Regular Plan is a preferred provider
organization (PPO) plan - that is, a network-based medical plan that
gives you a choice when it comes to getting health care. The Regular Plan
is available in most locations across the country and is the plan you're
automatically enrolled in once you become eligible for the Fund's health
care benefits. This is how it works. The network organization, which varies
by location, contracts with physicians, hospitals and other health care
providers to provide services at a contracted rate. (See the Summary
of Benefits for network information.) Neither you nor the Fund is
required to pay any amount over the contracted rate . |
Each time you need medical care, you have the option of seeing:
- Any network provider and paying a smaller percentage of the contracted
rate. This means less money out of your pocket; or
- Any non-network provider and paying a percentage of the R&C charge,
plus any amount over the R&C limit. This means your out-of-pocket costs
will be higher.
Whether you see a network provider or a non-network provider,
the Regular Plan covers a broad range of medical services and supplies, including
wellness benefits, hospital treatment, prescription drug benefits, and mental
health and substance abuse benefits. Keep in mind that you always have the freedom
to choose your provider and the services he/she recommends.
If You Live Outside The PPO Network Area
If you live in an area where you don't have access to the Regular Plan's
PPO network, the plan pays out-of-area benefits. You can choose any licensed
physician, nurse, therapist, hospital, lab or other health care facility you
wish whenever you need medical care. The Regular Plan's out-of-area option pays
a percentage of the cost of eligible expenses, up to the R&C limit, after
you meet the calendar-year deductible. (See the Summary
Of Benefits for specific percentages.)
If you're traveling in an area where there are PPO network providers, you
can use them. Or if you live near enough to a PPO provider that you want to
travel to that provider for care, you can do so. That way, you can receive the
advantage of network negotiated fees and reimbursement of eligible expenses
without R&C limits.
The Regular Plan's out-of-area option covers the same medical services and
supplies that are otherwise covered under the plan, including prescription drugs
and mental health and substance abuse treatment. You're responsible for filing
claims with the Fund to receive your reimbursement. For more information about
your benefits and what you and the plan pay, refer to the Summary
Of Benefits.
Sub-Topics:
Getting The Most From Your Plan
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Looking At Eligible And Ineligible Expenses
Filing A Claim
Knowing What To Do If Benefits Are Denied
Understanding Coordination Of Benefits (COB)
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