2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 35
(1)
Copays, including Prescription Drug Copays.
(2)
Deductibles.
(3)
Dental and vision benefits, other than those dental and vision expenses paid under the major medical
component of the Medical Plan.
(4)
Precertification penalties.
(5)
Any charges as defined in the General Exclusions and Limitations section.
Reimbursement for these non-accumulating expenses will continue at the percentage payable shown in the
Medical Schedule of Benefits, subject to the Medical Plan maximums.
The Medical Plan will not reimburse any expense that is not a Covered Expense. In addition, you must pay any
expenses that are in excess of the Usual and Customary Charges for Non-Participating Providers and any penalties
for failure to comply with requirements of the Medical Management and Precertification Program section of the
Medical Plan (if applicable) or any other penalty that is otherwise stated in this Medical Plan. This could result in
you having to pay a significant portion of your claim. None of these amounts will accumulate toward your Out-ofPocket Maximum.
You will not have to pay the Usual and Customary Charges for Non-Participating Providers when the service is
covered by the No Surprises Act, as described above. However, when a Non-Participating Provider obtains written
consent from you to charge a price higher than the contracted rates of your Plan, provided you are in a stable
condition, you may waive your right to not be balance billed. Please read any documentation provided to you from
a Non-Participating Provider thoroughly.
Once you have paid the Out-of-Pocket Maximum for eligible expenses Incurred during a Calendar Year, the Medical
Plan will reimburse additional eligible expenses Incurred during that year at 100%.
If you have any questions about whether an expense is a Covered Expense or whether it is eligible for accumulation
toward your Out-of-Pocket Maximum, please contact your Employer for assistance.
Integration of Deductibles and Out-of-Pocket Maximums
The Deductible amounts are combined for Network and out of Network Providers, however the Out-of-Pocket Limit
amounts for Network and out of Network Providers are separate amounts and do not integrate. In other words, you
will be required to satisfy the Out-of-Pocket Maximum amount for Participating Providers and Non- Participating
Providers separately.
Medical Expense Audit Bonus
The Medical Plan offers an incentive to all Covered Persons to encourage examination and self-auditing of eligible
medical bills to ensure the amounts billed by any provider accurately reflect the services and supplies received by
the Covered Person. The Covered Person is asked to review all medical charges and verify that each itemized
service has been received and the bill does not represent either an overcharge or a charge for services never
received. This self-auditing procedure is strictly voluntary; however, it is to the advantage of the Medical Plan as
well as the Covered Person to avoid unnecessary payment of healthcare costs.
In the event a self-audit results in elimination or reduction of benefits paid, 25% of the amount saved will be
reimbursed directly to the Employee (subject to a $10 minimum payment and a $500 maximum payment per
Calendar Year), provided the savings are accurately documented, and satisfactory evidence is submitted to the
Claims Administrator (e.g., a copy of the incorrect bill and a copy of the corrected billing).
This self-audit credit is in addition to the payment of all other applicable Medical Plan benefits for legitimate medical
expenses.
This credit will not be payable for expenses in excess of the Usual and Customary Charges or expenses that are
not covered under the Medical Plan, regardless of whether benefits paid are reduced.
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