IMPORTANT INFORMATION REGARDING YOUR MEDICAL BENEFITS
OUT-OF-NETWORK COSTS
The amount the plan pays for covered services provided by non-network providers is based on a maximum allowable amount for the specific service rendered . Although your plan stipulates an out-of-pocket maximum for out-of-network services , please note the maximum allowed amount for an eligible procedure may not be equal to the amount charged by your out-of-network provider . Your out-of-network provider may bill you for the difference between the amount charged and the maximum allowed amount . This is called balance billing and the amount billed to you can be substantial . The out-of-pocket maximum outlined in your policy will not include amounts in excess of the allowable charge and other non-covered expenses as defined by your plan . The maximum reimbursable amount for non-network providers can be based on a number of schedules such as a percentage of reasonable and customary or a percentage of Medicare . Contact your claims payer or insurer for more information . The plan document or carrier ’ s master policy is the controlling document , and this Benefit Highlight does not include all of the terms , coverage , exclusions , limitations , and conditions of the actual plan language .
ORGAN TRANSPLANT
The Plan Administrator requires that any Covered Person who is a candidate for any transplant procedure contact ICM before making arrangements for the procedure . This communication will identify certain types of procedures , or expenses associated with the procedures , which will not be covered under the Plan , before the actual services are rendered . Procedures must be Medically Necessary and warranted by your health condition . Any Transplant services that are not preauthorized will not be covered , whether or not the first occurrence and whether or not deemed Medically Necessary . See plan document for details .
WOMEN ’ S HEALTH & CANCER RIGHTS ACT
If you have had or are going to have a mastectomy , you may be entitled to certain benefits under the Women ’ s Health and Cancer Rights Act of 1998 (“ WHCRA ”). For individuals receiving mastectomy-related benefits , coverage will be provided in a manner determined in consultation with the attending physician and the patient , for :
� All stages of reconstruction of the breast on which the mastectomy was performed ;
� Surgery and reconstruction of the other breast to produce a symmetrical appearance ;
� Prostheses ; and
� Treatment of physical complications of the mastectomy , including lymphedema .
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under the plan . Therefore , the following deductibles and coinsurance apply :
$ 2,000 DEDUCTIBLE PPO PLAN ( Individual : 30 % to 0 % coinsurance and $ 2,000 deductible ; Family : 30 % to 0 % coinsurance and $ 4,000 deductible )
If you would like more information on WHCRA benefits , please call your Plan Administrator at 360.394.8635 or lcrowell @ suquamish . nsn . us .
HIPAA SPECIAL ENROLLMENT RIGHTS
The Suquamish Tribe Health Plan Notice of Your HIPAA Special Enrollment Rights
Our records show that you are eligible to participate in The Suquamish Tribe Health Plan ( to actually participate , you must complete an enrollment form and pay part of the premium through payroll deduction ).
A federal law called HIPAA requires that we notify you about an important provision in the plan - your right to enroll in the plan under its “ special enrollment provision ” if you acquire a new dependent , or if you decline coverage under this plan for yourself or an eligible dependent while other coverage is in effect and later lose that other coverage for certain qualifying reasons .
Prepared by Gallagher for the Employees of The Suquamish Tribe 12