5.4 PREFERRED PROVIDER PROGRAM
The Trust has entered into contracts with hospital facilities and a network of physicians and other medical providers to provide services and supplies to Participants at preferred rates, which reduce a Participant’s out-of-pocket expenses and reduce the overall cost to the Plan. While contracts provide for preferred rates, they do not allow for discrimination with regard to provided services. The Preferred Provider program provides a nationwide network of medical providers. Services through that network are payable at 80% of Covered Expenses. Services outside that network are payable at 60% of Covered Expenses. To locate a Preferred Provider in your area, please go online to www.959trusts.com and click on “Find Network Providers” or contact the Trust Customer Service Office.
The hospital Preferred Provider Program applies to Hospital emergency room, inpatient Hospital services, outpatient Hospital services, surgical services including maternity care, and home health services.
Covered Expenses at a Preferred Provider hospital are payable at 80%.
Covered Expenses for non-Emergency Services at a non-Preferred Provider hospital within 75 miles of a Preferred Provider Hospital are payable at 60% of the rate negotiated with the Preferred Provider for the same service after the $1,000 deductible has been applied (see the shaded box below). Because the rates negotiated with a Preferred Provider are normally lower than the rates charged by a non-Preferred Provider, the Participant will normally pay more than 40% of the total charges billed by a non-Preferred Provider. If the service is not available from a Preferred Provider, or if the service is provided at a location more than 75 miles from a Preferred Provider, Covered Expenses at the non-Preferred Provider hospital are payable at 60% of the UCR charges.
Emergency Services provided at a non-Preferred Provider hospital are payable as follows: services at hospitals located within 75 miles from a Preferred Provider hospital are covered at 80% of the Preferred Provider rate for the same service; services at hospitals located more than 75 miles from a Preferred Provider hospital are covered at 80% of the greater of the Preferred Provider rate for the same service or the UCR charge; and services that are not available from a Preferred Provider are covered at 80% of the UCR charge. However, if Medicare would pay more for the service, the Plan will match the Medicare reimbursement rate.
There is a separate, additional $1,000 deductible applied to each inpatient out-of-network hospital admission, in addition to the calendar year deductible.
- This out-of-network hospital deductible does not apply toward the Annual Out-of-Pocket Limit.
- This out-of-network hospital deductible may be waived in the event of an Emergency hospital admission.
For outpatient services rendered at a non-Preferred Provider facility, the reimbursement will be 60%, after a 50% penalty reduction is applied. In addition, any co-insurance will not apply towards the patient’s annual out-of-pocket limit.
HOSPITALS IN ALASKA
If a Participant goes to a hospital within 75 miles of a Preferred Provider hospital in Alaska that is not part of the Preferred Provider Program, the reimbursement rate will be 60% of the Preferred Provider rate. The additional $1,000 inpatient deductible will also apply to each scheduled non-Preferred Provider hospital admission, unless the service is not available from the Preferred Provider hospital in Alaska. Additional limits to Surgical Services are described below at Section 5.8.
HOSPITALS OUTSIDE OF ALASKA
If a Participant goes to an out-of-network hospital outside of Alaska, the reimbursement rate will be 60% and will apply to each hospital admission and outpatient procedure. Additional limits to Surgical Services are described below at Section 5.8.