How The Local 1014 Health Plan Works

Whether you just enrolled in The Local 1014 Health Plan or if you’re already covered by our Plan, below are some important insurance terms for your reference. A more comprehensive explanation of the details and coverage below can be found in the 2019 Summary Plan Description at www.local1014medical.org.

Each calendar year, you must meet the annual deductible before The Local 1014 Health Plan will begin to pay most covered expenses.

There are two types of deductibles:

1.Individual deductible: $200 per person (the deductible applies separately to each covered person)

2.Family deductible: $600 per family. When the combined individual deductible of three or more family members equals the family deductible amount, the family deductible is met. If you cover only yourself and one dependent, the individual deductible applies to each of you. Expenses incurred in one calendar year cannot be used to meet the deductible for the following calendar year.

Note: Prescription drug, dental, and vision expenses do not apply to the annual deductible.

Annual Deductible Coinsurance

Once you meet the deductible, you share cost with The Local 1014 Health Plan (this is called coinsurance). When you go to an in-network provider, The Local 1014 Health Plan will pay 90% of most allowable expenses and you will pay the balance. When you go to an out-of-network provider, The Local 1014 Health Plan will pay 70% of reasonable and customary charges and you pay the balance.

Copayments

For certain covered expenses, you pay a predetermined fee called a copayment or “copay.” For emergency room visits, a separate copayment of $50 applies to each visit when the covered person is not admitted directly from the emergency room to the hospital for continued necessary acute care. The emergency room copay does not apply in the case of an accident, when directed to the emergency room by a physician, when the covered person is transported by ambulance or if there is a reason to believe that the covered person has an emergency medical condition.

Out-of-pocket limit

To protect you from mounting medical bills resulting from serious illness of injury, The Local 1014 Health Plan limits the amount of coinsurance you must pay each year after you meet the annual deductible.

oIf you use in-network providers, your annual out-of-pocket limit is 10% of allowable expenses, up to $1,000 for individual or family coverage.

oIf you use out-of-network providers, your annual out-of-pocket limit is 30% of allowable expenses, up to $1,500 for individual or family coverage, plus any amounts above reasonable and customary charges. Note: The $1,000 in-network out-of-pocket limit is combined with, or counts towards, the $1,500 out-of-network limit.

Once you have reached the annual out-of-pocket limit after meeting your deductible, The Local 1014 Health Plan will pay 100% of allowable expenses, up to the specific Plan limits, for the remainder of that calendar year. Annual deductibles, prescription drug or other copayments, non-covered expenses and amounts that exceed reasonable and customary charges do not count toward your out-of-pocket limit.