FREQUENTLY ASKED QUESTIONS Q. I am confused about how my benefits are coordinated with Medicare. A. Coordination Where Medicare Benefits are “Primary.” When Medicare benefits are primary to any benefits under the Plan, Medicare benefits are paid first, and payment of Plan benefits, if any, occurs second based on what Medicare has paid and other rules. For example, Medicare is primary to Plan benefits if you are eligible for Medicare benefits based on age or disability and your coverage under the Plan is not based on current employment (as in the case of coverage for Retired Participants and their Dependents and certain “COBRA” coverage). In cases where Medicare coverage is primary, the Plan coordinates benefits with Medicare on a “carve-out” basis. Medicare “carve-out” coordination of benefits where Medicare payments are “primary” works like this: Medicare determines their benefits first. Then Plan benefits are paid. For expenses payable under both Medicare and the Plan: Plan benefits will be reduced by Medicare benefits; and Plan benefits and Medicare benefits combined will not exceed the amount that would have been paid in the absence of Medicare. The amount of Covered Expenses not paid by Medicare or the Plan is accumulated until you have reached the annual out-of-pocket limit referred to in Section 5.3. Then the Plan pays for additional Covered Expenses incurred in that calendar year after Medicare pays its share. Coordination Where Medicare Benefits are “Secondary.” Medicare benefits are sometimes “secondary” to those under the Plan, meaning that Plan benefits are paid first and Medicare benefits, if any, are paid second. Further Discussion of Coordination of Plan Benefits with Medicare. For the full explanation of the rules on coordination of Plan benefits with Medicare, see Section 15.10 through 15.12. Q: I understood that my plan would pay up to $300 for one physical examination per calendar year. The explanation of benefits I received shows that you applied part of the charges to my deductible and only paid 70% of the balance. A. This happens when your physician has indicated on the billing statement that your examination was for a specific symptom or complaint. The diagnosis on the billing statement must state that the reason for your visit was for a routine physical examination. The Plan and Trust cannot change the physician’s diagnosis; you will need to contact your physician. Q. What is the name of our insurance company? A. Your benefit coverage is provided through the Alaska Teamster-Employer Welfare Trust, which is a multi-employer employee benefit plan governed by a federal law called ERISA, the Employee Retirement Income Security Act. Q. The doctor’s office needs my group number and identification number to file my claim. A. The Plan has no group number. The Eligible Employee’s or Retired Participant’s social security number is the identification number or there is an Alternate Identification Number that is reflected on the eligibility cards that can also be used in lieu of the Eligible Employee’s or Retired Participant’s social security number. Q: What does the limit to “Usual, Customary and Reasonable” charges mean? A. The Plan will not pay charges above the “Usual, Customary and Reasonable” rate for medical services or supplies. A charge that does not meet all three of those requirements – by being “usual,” “customary,” and “reasonable” – will be adjusted by the Plan or eliminated. A charge is “usual” if it is no more than the charge that the medical provider most frequently makes to the majority of patients. A charge is “customary” if it is equal to or less than the 85th percentile rate established for the geographic area by the Plan’s third party service, which analyzes appropriate health care charges. A charge is “reasonable” if the service or supply is justified by the circumstances, and is not performed too frequently or at an unreasonable time.