Catastrophic Plan: Plan Design
This section will help participants understand how benefits are payable under the Catastrophic plan.
Network Benefits
If a participant receives services from a network provider, he or she generally saves money because providers in the PPO network have agreed to charge patients lower, negotiated rates. The participant must meet the $2,000 deductible for most services. Then, whenever the participant receives medical services, he or she pays a percentage of the provider's negotiated rate.
There are no claim forms to file because the PPO network provider submits claims for the participant.
Out-of-Network Benefits
When a participant uses a provider who does not participate in the PPO network, that provider is considered to be out of network.
Each participant must meet the $2,000 deductible. Then, whenever the participant receives medical services, the plan pays a percentage of the cost of services, up to the reasonable and customary limit. The participant pays the remaining percentage (the coinsurance) plus any amount above the reasonable and customary limit.
Participants who go to out-of-network providers may be responsible for filing their own claims for reimbursement. Participants should check with their provider for information on their payment and claim filing practices.
Reasonable and Customary (R&C) Limit
The R&C limit is the maximum amount the plan will pay for a covered service received from an out-of-network provider, based on what providers in the participant's geographic area charge for similar services. Participants are responsible for paying any difference between the R&C limit and the amount billed. The determination of what the reasonable and customary limit is for a specific medical service is within the sole discretion of the Claims Administrator and is not subject to challenge or review.
Multiple and Bilateral Surgical Procedures
Multiple surgical procedures consist of more than one surgical procedure performed on the same date of service during the same surgical session. Bilateral surgeries consist of surgery performed during the same surgical session through separate incisions to matching parts of the body (e.g., both shoulders). When multiple or bilateral surgical procedures are performed during the same operative setting, the allowed amount of secondary and subsequent procedures is reduced.
Major (first) procedure - 100% of R&C
Second procedure - 50% of R&C
Subsequent procedure - 25% of R&C
If multiple or bilateral surgical procedures are performed by network providers, participants will not have to pay any more as a result of the reduced amount. Participants who choose out-of-network providers could incur additional costs if the provider chooses to bill the member for the remaining balance.
Multiple Scan/Images Procedure
When multiple images of adjacent body parts are taken during a single session, a reduction will be applied to the technical component of the services performed. Professional fees billed separately are not affected.
Initial scan/imaging - 100% of R&C
Subsequent scan/imaging - 75% of R&C
If multiple or bilateral surgical procedures are performed by network providers, participants will not have to pay any more as a result of the reduced amount. Participants who choose out-of-network providers could incur additional costs if the provider chooses to bill the member for the remaining balance.
Prescription Drug Program
Prescription drugs are covered under the Catastrophic plan when they are purchased from a network pharmacy or through the mail order program. Participants may purchase prescription drugs at any pharmacy.
Retail Pharmacies
A participant who needs to take medication for a short period of time (up to 30 days) should locate the nearest network pharmacy. Either generic or brand name prescription drugs are covered at 70%, after the annual deductible has been met.
To find a participating pharmacy, participants can log on to their PPO network web site.
Prescription drugs are not covered if they are purchased from out-of-network pharmacies.
Mail Order
A participant who needs to use a long-term, maintenance medication (usually a prescription for more than 30 days) can fill his or her prescription through the PPO network mail order program. Through the mail order program, participants can receive up to a 90-day supply of medication, covered at 70%, after the annual deductible has been met. Prescriptions are mailed directly to the participant's home.
Health Savings Account (HSA) Eligible
The SAIC Catastrophic plan qualifies as a High Deductible Health Plan (HDHP) which, if elected, allows employees to qualify for a Health Savings Account (HSA) which is different from a healthcare flexible spending account. A standard healthcare flexible spending account (the plan offered by SAIC) cannot be used in conjunction with an HSA.
What is a Health Savings Account ("HSA")?
A Health Savings Account is an alternative to traditional health insurance; it is a savings product that offers a different way for consumers to pay for their health care. HSAs enable you to pay for current health expenses and save for future qualified medical and retiree health expenses on a tax-free basis.
You must be covered by a High Deductible Health Plan (HDHP) to be able to take advantage of HSAs. An HDHP generally costs less than what traditional health care coverage costs, so the money that you save on insurance can therefore be put into the Health Savings Account.
You own and you control the money in your HSA. Decisions on how to spend the money are made by you without relying on a third party or a health insurer. You will also decide what types of investments to make with the money in the account in order to make it grow. Consumers can sign up for HSAs with banks, credit unions, insurance companies and other approved companies.
