FREQUENTLY ASKED QUESTIONS

• A flat-dollar amount of covered expenses that you pay per calendar year before coinsurance benefits are payable.
• There is a per-individual deductible and a per-family deductible.
• If you are enrolled in a family plan, you pay no more than three individual deductibles in a calendar year not to exceed the family deductible.  Therefore, if only one individual uses the plan in a calendar year, you pay only one individual deductible.  If only two individuals use the plan in a calendar year, you pay only two individual deductibles.  If three or more individuals use the plan in a calendar year you pay only three individual deductibles and will have met your maximum family deductible for the calendar year.
• The PPO/Indemnity family deductible for out-of-network services is not an even multiple of the single deductible.  All out-of-network deductible expenses paid by each individual in a family plan accumulate toward the total annual family deductible.  Therefore, once two or more individuals pay the out-of-network family deductible, the family meets the out-of-network deductible for the calendar year.

• After the deductible is met each year, the plan pays a percentage of most covered expenses and you pay a percentage; your percentage is coinsurance.
• If you are enrolled in the PPO/Indemnity Plan, the percentage paid by the plan for in-network expenses is greater than the percentage paid for out-of-network expenses (an incentive for you to use in-network providers).
• In general and as defined by the plans, coinsurance applies to hospital services, in-hospital physician services, diagnostic x-ray and lab, outpatient services, physical/speech/occupational/radiation/chemo therapy, specialists, surgeons, other physician services, and durable medical equipment.

• The plan limits the amount you must pay in a calendar year for coinsurance.  When your out-of-pocket coinsurance payments reach the annual maximum, the remaining eligible expenses subject to coinsurance are paid in full for the remainder of the calendar year.
• Your annual coinsurance limit is per individual in a calendar year; however, a family plan pays no more than three individual coinsurance limits in a calendar year (not to exceed the family coinsurance limit).
• If you are enrolled in a family plan and only one individual uses the plan in a calendar year, you pay up to only one individual annual coinsurance limit and then the plan pays 100% for the remainder of the calendar year for those expenses subject to coinsurance.  If only two individuals use the plan, you pay up to only two individual annual coinsurance limits.  If three or more individuals use the plan, you pay up to only three individual annual coinsurance limits since you have met your maximum annual coinsurance limit for the calendar year.
• The PPO/Indemnity family coinsurance limit for out-of-network services is not an even multiple of the single coinsurance limit.  All out-of-network coinsurance expenses paid by each individual in a family plan accumulate toward the total annual coinsurance limit.  Therefore, once three or more individuals pay the out-of-network family coinsurance limit, the family meets the out-of-network family coinsurance limit for the calendar year.

• Co-pay is not subject to the deductible and coinsurance.  Co-pay has no annual cap (limit/maximum).  You pay a flat dollar co-pay or percentage co-pay each time you use the service and the plan pays the balance for the service.
• In general and as defined by the plans, a co-pay applies to each in-network office visit, urgent care visit, emergency room visit (in-network and out-of-network), and prescription medication (retail and mail order).

• In general, when a plan has a deductible and coinsurance, the provider will bill the third party administrator first to determine the contracted rate.  Then the provider will balance bill you for the amount not paid which should be the deductible and coinsurance amount.
• Some providers may request payment up-front for any non-covered service as well as for co-payments, deductibles and coinsurance amounts.
• Providers will typically ask you to pay the co-pays at the time of your office visit or urgent care visit.
• Regarding in-network prescription drugs (retail and mail-order), you pay the co-pay when you get your prescription filled.
• Regarding out-of network retail prescription drugs under the PPO/Indemnity Plan, you pay for the entire cost of the drug when you get the prescription filled and you turn your claim in to the third party administrator for reimbursement.  There is no out-of-network prescription drug benefit under the UnitedHealthcare EPO Plan.
• Emergency room visits are much more likely to be billed in full to the third party administrator, and the facility will bill you after the health plan pays.

• MPS is self-funded (self-insured), which means MPS (not an insurance company) pays the entire cost of all claims.  MPS only pays its third party administrators (UnitedHealthcare and Medco) fixed administrative fees to handle claim payments, customer service and network management.  The checks UHC and Medco issue to providers for claim payments are charged to an MPS bank account.  Employee premium contributions are used toward these provider payments.
• When plan costs are lowered or maintained, school budget allocations are not further reduced due to cost of benefits.