The Traditional plan is administered by Allegiance who contracts with health care providers to offer plan members a provider network (providers who have agreed to accept certain payments for specific services).
How The Plan Works:
Plan members receive medical services from a participating health care provider. If the provider is a preferred provider, the provider submits a claim for the member. The administrator processes the claim and sends an Explanation of Benefits (EOB) to the member, showing the member’s payment responsibilities (deductible and/or coinsurance costs) to the provider. The plan then pays the remaining allowable charges, which the provider accepts as full payment.
If your provider is not an in-network provider you may have to pay the entire fee to the provider and file a claim.
You can protect yourself from unexpected expenses by making sure a provider is in-network (providers who contract with a plan to manage the delivery of care for plan members). If you see a provider that is out-of-network (a provider not in a plans’ network) you are subject to paying a higher coinsurance and can be balance billed for the difference between their charge and the allowable charge.
- Traditional Plan – (available everywhere)
- An annual deductible – the amount you pay
each benefit year before the plan begins to pay.
- Coinsurance – a percentage of allowable
fees you pay until you reach the benefit year’s coinsurance maximum.
- In-Network providers – Providers (including facilities) who contract with the plan
administrator to deliver care according to agreed upon prices.
- Out of Network providers – You pay 25%
coinsurance for services of an in-network
provider; and 35% for an out-of-network provider. Out-of-network providers can also balance bill you for any difference between their charge and the allowable charge.
Important 2013-14 Benefit Information