Health and Welfare Summary Plan Description

• Health and Welfare SPD / Article VIII / Self-Funded PPO Option >>

8.5 Limits on Covered Charges

1. Deductible. The deductible is $150 per Covered Individual up to a maximum of $300 per family for each calendar year. This is the out-of-pocket expense for which you are responsible. Charges that are not Covered Charges and charges you pay as a coinsurance may not be used to satisfy the deductible amount. The deductible amount is subtracted from your Covered Charges and the remaining amount is multiplied by the coinsurance percentage to determine your amount payable. If charges in the last three months of a calendar year are applied toward the deductible, these charges will also be applied toward the deductible for the next calendar year. After the family deductible has been satisfied in a calendar year, no further deductible is required of that family unit for charges incurred in the remainder of that calendar year.
   
   
2. Coinsurance. Except as provided otherwise in this section, after the deductible described in subsection (a) has been satisfied, Covered Charges will be paid at 80% of the contracted rate (100% for mental health and substance abuse charges) incurred in a calendar year performed by a Preferred Provider or at a Preferred Provider facility (i.e., an "in-network" provider or facility), and at 60% of Reasonable and Customary charges if not performed by a Preferred Provider or at a Preferred Provider facility (i.e., an "out-of-network" provider or facility), including for mental health and substance abuse charges. The 20% (or 40%) balance is your coinsurance, and is an out-of-pocket expense for which you are responsible. Once you or your Dependent have accumulated the maximum out-of-pocket Covered Charges described in subsection (d), the Plan will pay the balance of Covered Charges incurred during the remainder of the calendar year, up to the limit stated in subsection (g), at 100% for services performed in-network and at 80% for services performed out-of-network. Your Covered Charges are paid only to the extent provided in this section, so you should use in-network Physicians and Hospitals if you wish to minimize your out-of-pocket cost.
   
   
3. Out-Patient Hospital Benefits. The Plan will pay the first $5,000 of out-patient Hospital Covered Charges in a calendar year at 100% when a Covered Individual:
   1. receives emergency out-patient treatment at a Hospital within 24 hours from the occurrence of an accident;
   2. receives emergency out-patient treatment for a condition characterized by acute symptoms that are of sufficient severity to cause a reasonable expectation, in the absence of immediate medical attention, that the health of the individual is in serious jeopardy; or
   3. requires Hospital facilities as an out-patient for a surgical operation.
      
      
4. This section modified by Plan Announcement.
   Maximum Annual Out-of-Pocket Limit. A Covered Individual shall not be required to pay in-network Covered Charges exceeding $1,500 per calendar year. Once a Covered Individual has paid $1,500 of out-of-pocket Covered Charges in a calendar year, the Plan will pay the balance of Covered Charges incurred during the remainder of the calendar year at 100% for in-network services and at 80% for out-of-network services. In no event will the out-of-pocket Covered Charges exceed the maximum amount allowable under the Affordable Care Act, which for 2015 is $13,200 per family ($6,600 single).
   
   Special Rules for Out-of-Network Emergency Care. If you experience a medical condition with acute symptoms (including severe pain) such that you require emergency care to address a serious threat to your (or your unborn child's) health and/or the functioning of an organ or other part of your body, you may seek emergency care without prior authorization and without regard to whether the emergency care provider (e.g., a hospital) is in-network or out-of-network. The Plan will cover the charges of an out-of-network emergency care provider at least to the extent of the greatest of (i) what the Plan negotiated for the services with in-network providers (excluding any in-network copayment or co-insurance imposed on the Participant or Dependent), (ii) the provider's Reasonable and Customary Charges minus any co-pays and co-insurance that would have applied to an in-network provider, and (iii) the amount that would be paid by Medicare minus any co-pays and co-insurance that would have applied to an in-network provider. The preceding sentence will be applied in accordance with 45 C.F.R. §147.138(b).
   
   
5. Retirees. In general, the provisions of this article apply similarly to covered Retirees, except that the Plan will offset Covered Charges for a Medicare-eligible Retiree or Dependent by the amount payable by Medicare or the amount that would be payable by Medicare if the Covered Individual had enrolled in Medicare Parts A and B. (See Section 4.5(b).) Payments made pursuant to Medicare are subject to the satisfaction of any deductibles and the application of any Plan benefit maximums or coinsurance.
   
   
6. Maximum Annual Plan Benefit. Effective February 1, 2014, the Plan imposes no annual maximum.