Welfare Notes - April 2014

April, 2014

The Health Net PPO Plan

A participant's annual PPO deductible and the PPO copayments and coinsurance amounts (up to the first $1,000) will be reimbursed by the SUP Welfare Plan upon submission of the Health Net payment explanation of benefits and proper receipts. If you use a Non-PPO provider, you will only be reimbursed up to the out of pocket amounts that would have been reimbursable had you used a PPO provider. Following are several examples:

  • The Health Net Plan pays 80% of charges if a participant uses a PPO provider and 60% of charges if a participant uses a non-PPO provider. In this instance, a participant using a non-PPO provider will only be reimbursed the difference between the 60% allowed by Health Net and 80% which is the amount payable for a PPO provider (leaving 20% of the charges as the member's responsibility plus any amounts exceeding Health Net's customary and reasonable charge allowance). So for a $2,000 charge from a non-PPO provider, Health Net would pay $1,200 (assuming the deductible has been met); the Trust would reimburse you $400 and you will be required to pay $400.
     
  • The Health Net Plan requires a $20 member copayment for an office visit to a PPO provider. A participant using a non-PPO provider will be reimbursed a maximum of $20 for an office visit. So for a $150 office visit charge from a non-PPO provider, Health Net would pay $90 (assuming the deductible has been met); the Trust would reimburse you $20 and you will be required to pay $40.
     
  • The Health Net Plan requires an additional $500 copayment for inpatient hospitalization at a non-PPO facility. The $500 amount will not be reimbursable to you as this copayment applies only to non-PPO providers.

Spouses and dependents are not eligible for any deductible or coinsurance reimbursements. Please contact the Plan Office if you have any questions.

 

 

Michelle Chang, Administrator  
Patty Martin  
Virginia Briggs, Claims   
Michael Jacyna, Eligibility