HOW MEDICAL BENEFITS ARE PAID

Benefits are available for services and supplies necessary to diagnose, care for, or treat a physical or medical condition. To be eligible for benefits under the Plan, the service or supply must be:

• Medically Necessary, and
• A covered service under the Plan.

The Plan’s benefit payment will be based on:

• Plan provisions, including any limitations or exclusions, and
• The Allowable Expense of the service or supply.

Virtual visits with your provider by phone, video, or both are covered the same as an in-office visit. (Note: this is separate from services provided through Teladoc.)

Use PPO’s to Save Money

To be sure you maximize your benefits and reduce your cost be sure to review the Health Trust’s preferred providers (PPOs) information.

Incentive for Mat-Su Borough Residents to Use Alaska Regional Hospital

The Plan will pay an incentive to participants who live in the Mat-Su Borough and choose to receive treatment at Alaska Regional Hospital instead of Mat-Su Regional Medical Center. The incentive payment will be 10% of the amount the Plan pays Alaska Regional Hospital, up to $500 for outpatient procedure/surgery services and $1,000 for inpatient hospital services for each treatment episode. Each period of hospitalization and each day of outpatient surgery, from facility admittance to check out, is considered one treatment episode. The incentive:

• Applies to inpatient services or outpatient procedures/surgery only;
• Is based on the facility fees only; and
• Is only available when the Plan is the patient’s primary medical plan.

The incentive does not apply to testing or radiology not provided as part of an inpatient hospitalization or outpatient procedure/surgery. In order to receive the incentive payment, you must complete an Incentive Request form and submit it to the Health Trust Administrator within 365 days of the date of service.

Employee Elected Second Opinions

The Plan pays the covered expenses for obtaining a second surgical opinion when the first surgeon has recommended non-emergency surgery, according to the Reimbursement Percentage shown in the Benefits Summary section. Charges for X-rays and diagnostic tests required in connection with the second opinions are included. However, to avoid duplication, the attending physician is encouraged to share his X-ray and test results with the consulting physician(s). To qualify for second opinion benefits, the proposed surgery:

• Must be recommended by the physician who plans to perform it;
• Will, if performed, be covered under this Medical Plan; and
• Must require General or Spinal Anesthesia.

The second opinion must be obtained before you are hospitalized. You may choose your consulting physician.

Plan Reimbursement

The amount the ASEA Health Trust Plan pays for medical care is based on the Allowable Expenses of the Medical Plan Option in which you are enrolled.

Reimbursement for Medical Care

*The Allowable Expense for Non-PPO services within the Municipality of Anchorage/Mat-Su Borough is based on contracted price at the PPO for inpatient visits. Outpatient visits are based on the case rate or 50% of the billed charges. You are responsible for any charges in excess of the Trust's Allowable Expense. The excess charges will not apply to the Annual Out-of-Pocket Limit and will not be paid at 100% when the Annual Out-of-Pocket Limit is reached.

More Details:

• Benefit Summary and Medical sections of the Plan Booklet