Section 4. Your costs for covered services

In this section:

• Copayments
• Cost-Sharing
• Deductible
• Coinsurance
• If your provider routinely waives your cost
• Waivers
• Member Responsibility
• Differences between our allowance and the bill
• Your Catastrophic Protection
• Carryover
• If We Overpay You
• When Government Facilities Bill Us
• When You Are age 65 Or Over And You Do Not Have Medicare
• When You Have The Original Medicare Plan (Part A, Part B, Or Both)

This is what you will pay out-of-pocket for your covered care:

Copayments		High Option: A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services. Example: Under the High Option, when you see your PPO physician you pay a copayment of $18 per visit. Consumer Driven Option: There are no copayments under the Consumer Driven Option. Note: If the billed amount or the Plan allowance that providers we contract with have agreed to accept as payment in full is less than your copayment, you pay the lower amount.
Cost-Sharing		Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.
Deductible		A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible. High Option If you use PPO providers, the calendar year deductible is $275 per person. Under a family enrollment, the deductible is satisfied for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $550. If you use non-PPO providers, your calendar year deductible increases to a maximum of $500 per person ($1,000 per family). Whether or not you use PPO providers, your calendar year deductible will not exceed $500 per person ($1,000 per family). We also have a separate deductible for mental health and substance abuse benefits. The in-network deductible is $275 per person. Under a family enrollment, this deductible is satisfied for all family members when the combined in-network covered expenses applied to this deductible for all family members reach $550. The out-ofnetwork deductible is $750 per person each calendar year with no family maximum. If the billed amount (or the Plan allowance that providers we contract with have agreed to accept as payment in full) is less than the remaining portion of your deductible, you pay the lower amount. Example: If the billed amount is $100, the provider has an agreement with us to accept $80, and you have not paid any amount toward meeting your calendar year deductible, you must pay $80. We will apply $80 to your deductible. We will begin paying benefits once the remaining portion of your calendar year deductible ($275) has been satisfied. Note: If you change plans during Open Season, and the effective date of your new plan is after January 1 of the next year, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan. If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option. However, if you change from High Option to Consumer Driven Option or from Consumer Driven Option to High Option, during the year, expenses incurred as of the effective date of the option change are subject to the benefit provisions of your new option. Consumer Driven Option: There is no calendar year deductible under the Consumer Driven Option. Also, there is no separate deductible for mental health and substance abuse benefits under the Consumer Driven Option.
Coinsurance		High Option: Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn't begin until you meet your deductible (High Option) or your Member Responsibility (Consumer Driven Option). Example: You pay 30% of our allowance for office visits to a non-PPO physician. Consumer Driven Option: Coinsurance is the percentage of our allowance that you must pay for your care after you have used up your Personal Care Account (PCA) and paid your Member Responsibility.
If your provider routinely waives your cost		If your provider routinely waives (does not require you to pay) your copayments, deductibles, or coinsurance, the provider is misstating the fee and may be violating the law. In this case, when we calculate our share, we will reduce the provider's fee by the amount waived. For example, if your physician ordinarily charges $100 for a service but routinely waives your 30% coinsurance, the actual charge is $70. We will pay $49 (70% of the actual charge of $70).
Waivers		In some instances, an APWU Health Plan provider may ask you to sign a "waiver" prior to receiving care. This waiver may state that you accept responsibility for the total charge for any care that is not covered by your health plan. If you sign such a waiver, whether you are responsible for the total charge depends on the contracts that the Plan has with its providers. If you are asked to sign this type of waiver, please be aware that, if benefits are denied for the services, you could be legally liable for the related expenses. If you would like more information about waivers, please contact us at 1-800/222-APWU.
Member Responsibility		High Option: Does not apply. Consumer Driven Option: Your Member Responsibility is your bridge between your Personal Care Account (PCA) and your Traditional Health Coverage. After you have exhausted your PCA, you must pay your Member Responsibility before your Traditional Health Coverage begins. Your Member Responsibility is generally $600 for a Self Only enrollment or $1,200 for a Self and Family enrollment. Your Member Responsibility in subsequent years may be reduced by rolling over any unused portion of your Personal Care Account remaining at the end of the calendar year(s).
Differences between our allowance and the bill		High Option: Our "Plan allowance" is the amount we use to calculate our payment for covered services. Fee-for-service plans arrive at their allowances in different ways, so their allowances vary. For more information about how we determine our Plan allowance, see the definition of Plan allowance in Section 10. Often, the provider's bill is more than a fee-for-service plan's allowance. Whether or not you have to pay the difference between our allowance and the bill will depend on the provider you use. PPO providers agree to limit what they will bill you. Because of that, when you use a preferred provider, your share of covered charges consists only of your deductible and coinsurance or copayment. Here is an example about coinsurance: You see a PPO physician who charges $150, but our allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, you pay just -- 10% of our $100 allowance ($10). Because of the agreement, your PPO physician will not bill you for the $50 difference between our allowance and his/her bill. Non-PPO providers, on the other hand, have no agreement to limit what they will bill you. When you use a non-PPO provider, you will pay your deductible and coinsurance -- plus any difference between our allowance and charges on the bill. Here is an example: You see a non-PPO physician who charges $150 and our allowance is again $100. Because you've met your deductible, you are responsible for your coinsurance, so you pay 30% of our $100 allowance ($30). Plus, because there is no agreement between the non-PPO physician and us, the physician can bill you for the $50 difference between our allowance and his/her bill. The following table illustrates the examples of how much you have to pay out-of-pocket for services from a PPO physician vs. a non-PPO physician. The table uses our example of a service for which the physician charges $150 and our allowance is $100. The table shows the amount you pay if you have met your calendar year deductible. EXAMPLE PPO physician Non-PPO physician Physician's charge $150 $150 Our allowance We set it at:   100 We set it at:   100 We pay 90% of our allowance:   90 70% of our allowance:   70 You owe: Coinsurance 10% of our allowance:   10 30% of our allowance:   30 +Difference up to charge? No:   0 Yes:   50 TOTAL YOU PAY $10 $80   Consumer Driven Option: PPO providers agree to accept our plan allowance so if you use a PPO Provider, you never have to worry about paying the difference between the plan allowance and the billed amount for covered services. If your covered expenses are being paid out of your Personal Care Account or if you are receiving in-network covered preventive services, the plan will pay 100%. If you have exhausted your Personal Care Account, you will be responsible for paying your Member Responsibility and also coinsurance under the Traditional Health Coverage. Non PPO Providers: If you use a non-PPO provider, you will have to pay the difference between the plan allowance and the billed amount only if you use up your Personal Care Account for the year. Note that it usually makes sense to use PPO providers because it will make your Personal Care Account go much further since money left in your Personal Care Account can be rolled over to be used in the next year.
Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance, copayments, and Member Responsibility		There is a limit to the amount you must pay out-of-pocket for coinsurance for the year for certain charges. When you have reached this limit, you pay no coinsurance for covered services for the remainder of the calendar year. High Option: PPO benefit: Your out-of-pocket maximum is $4,000 for either a Self Only or a Self and Family enrollment if you are using PPO providers. Only eligible expenses for PPO providers count toward this limit. Non-PPO benefit: Your out-of-pocket maximum is $10,000 for either a Self Only or a Self and Family enrollment if you are using non-PPO providers. Eligible expenses for network providers also count toward this limit. Your eligible out-of-pocket expenses will not exceed this amount whether or not you use network providers. Out-of-pocket expenses for the purposes of this benefit are: The 10% you pay for PPO Inpatient hospital charges, Surgical, Maternity and Diagnostic and treatment services The 30% you pay for non-PPO Inpatient hospital charges, Surgical, Maternity and Diagnostic and treatment services; and The copayment of $18 for outpatient visits to PPO physicians The following cannot be included in the accumulation of out-of-pocket expenses: Expenses in excess of our allowance or maximum benefit limitations Expenses for out-of-network mental health or substance abuse Any amounts you pay because benefits have been reduced for non-compliance with this Plan's cost containment requirements (see pages 11, 12, 13, 14, 15 and 16) Covered expenses applied to the $275 or $500 calendar year deductibles Covered expenses applied to the $275 deductible for in-network mental health or substance abuse care The $300 per admission deductible for non-PPO Inpatient hospital charges Expenses for prescription drugs Expenses in excess of visit maximums for physical, occupational and speech therapy (see page 27) Expenses incurred in excess of the $90 per day provided under home nursing care (see page 30); and Expenses in excess of hospice care and preventive care maximums Consumer Driven Option: If you have exceeded your Personal Care Account and met your Member Responsibility the following would apply: In-network benefit: Your out-of-pocket maximum is $3,000 for a Self Only enrollment or $4,500 for a Self and Family enrollment if you are using network providers. Only eligible expenses for network providers count toward this limit. Out-of-network benefit: Your out-of-pocket maximum is $9,000 for either a Self Only or a Self and Family enrollment if you are using out-of-network providers. Eligible expenses for network providers also count toward this limit. Your eligible out-of-pocket expenses will not exceed this amount whether or not you use network providers. Out-of-pocket expenses for the purposes of this benefit are: The 15% you pay for in-network Inpatient and Outpatient hospital charges, Surgical, Medical, Maternity and Emergency services under the Traditional Health Coverage The 40% you pay for out-of-network Inpatient and Outpatient hospital charges, Surgical, Medical, Maternity and Emergency services under the Traditional Health Coverage The following cannot be included in the accumulation of out-of-pocket expenses: Any expenses paid by the Plan under your Personal Care Account Any expenses paid by the Plan under your In-network Preventive Care benefit Any expenses you must pay under your Member Responsibility Expenses in excess of our allowance or maximum benefit limitations or expenses not covered under the Traditional Health Coverage Expenses for out-of-network mental health or substance abuse care Expenses you pay for prescription drugs under your Traditional Health Coverage Dental care or Vision care expenses above the limitations provided under your Personal Care Account Any amounts you pay because benefits have been reduced for non-compliance with this Plan's cost containment requirements (see pages 11, 12, 13, 14, 15 and 16) Expenses in excess of Hospice care maximums
Carryover		If you changed to this Plan during open season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan's catastrophic protection benefit during the prior year will be covered by your old plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your old plan's catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your old plan will first apply your covered out-of-pocket expenses until the prior year's catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your old plan will pay these covered expenses according to this year's benefits; benefit changes are effective January 1. Note: If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your old option to the catastrophic protection limit of your new option.
If we overpay you		We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments. We will generally first seek recovery from the provider if we paid the provider directly, or from the person (covered family member, guardian, custodial parent, etc.) to whom we sent our payment.
When government facilities bill us		Facilities of the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member. They may not seek more than their governing laws allow.

When you are age 65 or over and you do not have Medicare

Under the FEHB law, we must limit our payments for inpatient hospital care and physician care to those benefits you would be entitled to if you had Medicare. Your physician and hospital must follow Medicare rules and cannot bill you for more than they could bill you if you had Medicare. You and the FEHB benefit from these payment limits. Outpatient hospital care is not covered by this law; regular Plan benefits apply. The following chart has more information about the limits.