In 2015, Trust members received an updated Summary Plan Description (SPD) and Schedule of Benefits. The SPD is a summary of the main features of your benefit program. It contains general information only and is designed to give you a broad picture of your benefits. The Schedule of Benefits supplements the SPD with information on preventive services covered under your medical plan and cost-sharing obligations applicable to your health care benefits, as well as contact information.
Additionally, in the fall of each year the Trust sends members an annual Benefit Highlights, which contains addendums to the Health Care Benefits Summary (Schedule of Benefits) and SPD. Benefit Highlights summarizes changes and plan design enhancements each year. Below are the current Benefit Highlights and Plan Documents. Previous year's documents are archived under Trust Communications.
If there is any conflict between the wording in the Plan Document, SPD, Schedule of Benefits, Benefit Highlights or any applicable HMO or Medicare Advantage plan certificate of coverage, the Plan Document governs, unless preempted by state or federal law.
A primary enrollee is responsible for paying certain costs of health care coverage including his or her monthly contribution, annual deductible, co-insurance, co-payment, and annual out-of-pocket maximum.
Cost Sharing Glossary
Monthly Contribution – The amount a primary enrollee may be required to pay monthly for health care coverage. The amount can vary based on enrollment as a "single" or "family," “Protected” or “General,” or the plan option selected (e.g., TCN or HMO).
Annual Deductible – The aggregate amount a primary enrollee may be responsible for paying each calendar year for covered services prior to the plan making a payment. “Single” and “family” deductibles may apply. Once the deductible is met, co-insurance may apply.
Co-insurance – The amount a primary enrollee may be required to pay to a provider for covered services or supplies once any applicable deductible(s) is (are) met. The amount is calculated as a percentage of the allowed amount for covered services. For example, if the co-insurance were 80% / 20%, the plan would pay 80% of the allowed amount and you would be responsible for the remaining 20%. The co-insurance percentages may vary depending on whether or not the services are obtained from in-network providers.
Co-payment – A fixed-dollar amount that a primary enrollee may be required to pay to a provider for specific covered services or supplies (such as emergency room visits or prescription drug) at the time the service or supply is provided. Primary enrollees are responsible for any required co-payments, regardless of the status of any applicable ductibles or out-of-pocket maximums.
Annual Out-of-Pocket Maximum – A maximum aggregate dollar amount a primary enrollee may be required to pay during a given calendar year for the deductibles and co-insurance amounts charged for certain covered services and supplies. Separate “in-network” and “out-of-network” out-of-pocket maximums may apply.
Sanction – An amount of otherwise covered or potentially covered expense that a primary enrollee incurs for failure to follow plan provisions (such as additional amounts incurred for failure to predetermine a Hospital admission). Please note that certain expenses may not be applied toward your deductible or out-of-pocket maximum. In addition, some expenses may not be paid at 100% even after you meet your out-of-pocket Maximum.