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DALLAS COUNTY HOSPITALDISTRICT d/b/a PARKLAND HEALTH& HOSPITAL SYSTEMDALLAS TXHealth BookletRevised 01-01-2022BENEFITS ADMINISTERED BY
Table of ContentsINTRODUCTION . 1PLAN INFORMATION. 2MEDICAL SCHEDULE OF BENEFITS . 4TRANSPLANT SCHEDULE OF BENEFITS . 13PRESCRIPTION SCHEDULE OF BENEFITS. 14INCENTIVE SOLUTIONS . 15OUT-OF-POCKET EXPENSES AND MAXIMUMS . 16ELIGIBILITY AND ENROLLMENT . 18TERMINATION . 24COBRA CONTINUATION OF COVERAGE. 26UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT OF 1994 . 35PROVIDER NETWORK. 36COVERED MEDICAL BENEFITS . 39TELADOC SERVICES . 50HOME HEALTH CARE BENEFITS . 51TRANSPLANT BENEFITS . 52PRESCRIPTION BENEFITS . 55MENTAL HEALTH BENEFITS . 56SUBSTANCE USE DISORDER AND CHEMICAL DEPENDENCY BENEFITS. 58UMR CARE: CLINICAL ADVOCACY RELATIONSHIPS TO EMPOWER. 59COORDINATION OF BENEFITS . 63RIGHT OF SUBROGATION, REIMBURSEMENT, AND OFFSET . 67GENERAL EXCLUSIONS . 70CLAIMS AND APPEAL PROCEDURES . 76FRAUD . 85OTHER FEDERAL PROVISIONS . 86HIPAA ADMINISTRATIVE SIMPLIFICATION MEDICAL PRIVACY AND SECURITY PROVISION . 88PLAN AMENDMENT AND TERMINATION INFORMATION. 95GLOSSARY OF TERMS . 96
DALLAS COUNTY HOSPITAL DISTRICT d/b/a PARKLAND HEALTH & HOSPITAL SYSTEMGROUP HEALTH BENEFIT PLANSUMMARY PLAN DOCUMENTINTRODUCTIONThe purpose of this document is to provide You and Your covered Dependents, if any, with summaryinformation on benefits available under this Plan as well as information on a Covered Person's rights andobligations under the DALLAS COUNTY HOSPITAL DISTRICT d/b/a PARKLAND HEALTH & HOSPITALSYSTEM Health Benefit Plan (the "Plan"). As a valued Employee of DALLAS COUNTY HOSPITALDISTRICT d/b/a PARKLAND HEALTH & HOSPITAL SYSTEM, we are pleased to sponsor this Plan toprovide benefits that can help meet Your health care needs. Please read this document carefully andcontact Your Human Resources or Personnel office if You have questions.DALLAS COUNTY HOSPITAL DISTRICT d/b/a PARKLAND HEALTH & HOSPITAL SYSTEM is namedthe Plan Administrator for this Plan. The Plan Administrator has retained the services of independentThird Party Administrators to process claims and handle other duties for this self-funded Plan. The ThirdParty Administrators for this Plan are UMR, Inc. (hereinafter "UMR") for medical claims, and MedImpactfor pharmacy claims. The Third Party Administrators do not assume liability for benefits payable underthis Plan, as they are solely claims paying agents for the Plan Administrator.The employer assumes the sole responsibility for funding the Plan benefits out of general assets;however, Employees help cover some of the costs of covered benefits through contributions, Deductibles,out-of-pocket, and Plan Participation amounts as described in the Schedule of Benefits. All claimpayments and reimbursements are paid out of the general assets of the employer and there is noseparate fund that is used to pay promised benefits.Some of the terms used in this document begin with a capital letter, even though the term normally wouldnot be capitalized. These terms have special meaning under the Plan. Most terms will be listed in theGlossary of Terms, but some terms are defined within the provision the term is used. Becoming familiarwith the terms defined in the Glossary will help to better understand the provisions of this Plan.Individuals covered under this Plan will be receiving an identification card to present to the providerwhenever services are received. On the back of this card are phone numbers to call in case of questionsor problems.This document summarizes the benefits and limitations of the Plan and will serve as the Summary PlanDocument and Plan document. Therefore it will be referred to as both the Summary Plan Document andPlan document.This document becomes effective on January 1, 2015.-1-7670-00-410761
PLAN INFORMATIONPlan NameDALLAS COUNTY HOSPITAL DISTRICT d/b/aPARKLAND HEALTH & HOSPITAL SYSTEM GROUPBENEFIT PLANName And Address Of EmployerDALLAS COUNTY HOSPITAL DISTRICT d/b/aPARKLAND HEALTH & HOSPITAL SYSTEM5200 HARRY HINES BLVDBENEFITS DEPARTMENT - BLDG BDALLAS TX 75235Name, Address And Phone NumberOf Plan AdministratorDALLAS COUNTY HOSPITAL DISTRICT d/b/aPARKLAND HEALTH & HOSPITAL SYSTEM5200 HARRY HINES BLVDBENEFITS DEPARTMENT - BLDG BDALLAS TX 75235214-590-8330Named FiduciaryDALLAS COUNTY HOSPITAL DISTRICT d/b/aPARKLAND HEALTH & HOSPITAL SYSTEMEmployer Identification NumberAssigned By The IRS75-6004221Type Of Benefit Plan ProvidedSelf-Funded Health & Welfare Plan providing Group HealthBenefitsType Of AdministrationThe administration of the Plan is under the supervision ofthe Plan Administrator. The Plan is not financed by aninsurance company and benefits are not guaranteed by acontract of insurance. UMR provides administrativeservices such as claim payments for medical claims.Funding Of The PlanEmployer and Employee ContributionsBenefits are provided by a benefit plan maintained on aself-insured basis by Your employer.Benefit Plan YearBenefits begin on January 1 and end on the followingDecember 31. For new Employees and Dependents, aBenefit Plan Year begins on the individual's Effective Dateand runs through December 31 of the same Benefit PlanYear.ComplianceIt is intended that this Plan meet all applicable laws. In theevent of any conflict between this Plan and the applicablelaw, the provisions of the applicable law shall be deemedcontrolling, and any conflicting part of this Plan shall bedeemed superseded to the extent of the conflict.-2-7670-00-410761
Discretionary AuthorityThe Plan Administrator shall perform its duties as the PlanAdministrator and in its sole discretion, shall determineappropriate courses of action in light of the reason andpurpose for which this Plan is established and maintained.In particular, the Plan Administrator shall have full and solediscretionary authority to interpret all plan documents,including this plan document, and make all interpretive andfactual determinations as to whether any individual isentitled to receive any benefit under the terms of this Plan.Any construction of the terms of any plan document andany determination of fact adopted by the PlanAdministrator shall be final and legally binding on allparties, except that the Plan Administrator has delegatedcertain responsibilities to the Third Party Administrators forthis Plan. Any interpretation, determination or other actionof the Plan Administrator or the Third Party Administratorsshall be subject to review only if a court of properjurisdiction determines its action is arbitrary or capriciousor otherwise a clear abuse of discretion. Any review of afinal decision or action of the Plan Administrator or theThird Party Administrators shall be based only on suchevidence presented to or considered by the PlanAdministrator or the Third Party Administrators at the timeit made the decision that is the subject of review.Accepting any benefits or making any claim for benefitsunder this Plan constitutes agreement with and consent toany decisions that the Plan Administrator or the Third PartyAdministrators make, in its sole discretion, and further,means that the Covered Person consents to the limitedstandard and scope of review afforded under law.-3-7670-00-410761
MEDICAL SCHEDULE OF BENEFITSBenefit Plan(s) 001All health benefits shown on this Schedule of Benefits are subject to the following: Deductibles, Co-pays,Plan Participation rates, and out-of-pocket maximums, if any. Refer to the Out-of-Pocket Expensessection of this plan document for more details.Benefits are subject to all provisions of this Plan including any benefit determination based on anevaluation of medical facts and covered benefits. Refer to the Covered Medical Benefits and GeneralExclusions sections of this plan document for more details.Important: Prior authorization may be required before benefits will be considered for payment. Failure toobtain prior authorization may result in a penalty or increased out-of-pocket costs. Refer to the UMRCARE section of this plan document for a description of these services and prior authorizationprocedures.Notes: Refer to the Provider Network section for clarifications and possible exceptions to the In-Networkor Out-of-Network classifications.If a benefit maximum is listed in the middle of a column on the Schedule of Benefits, that means that it isa combined Maximum Benefit for services that the Covered Person receives from all Tier 1, Tier 2 andTier 3 providers and facilities.Annual Deductible Per Calendar Year: Per Person Per FamilyPlan Participation Rate, Unless Otherwise StatedBelow: Paid By Plan After Satisfaction Of DeductibleAnnual Out-Of-Pocket Maximum:Note: Medical And Pharmacy Expenses AreSubject To The Same Out-Of-Pocket Maximum. Per Person Per FamilyAmbulance Transportation (Covered ForEmergencies And Transportation From PHHS ToAnother Hospital): Paid By PlanBreast Pumps: Paid By Plan After Deductible-4-ParklandHealth &HospitalSystemNetwork(Tier One)Benefit PanelServicesNetwork(Tier Two)Out-ofNetwork(Tier Three) 500 1,000 1,500 4,500 3,000 18,00090%70%50% 2,500 6,000 6,000 13,000 15,000 eductibleWaived)50%7670-00-410761
Contraceptive Methods And Counseling ApprovedBy The FDA:For Men: Paid By Plan After DeductibleFor Women: Paid By Plan After DeductibleDurable Medical Equipment: Paid By Plan After DeductibleParklandHealth &HospitalSystemNetwork(Tier One)Benefit PanelServicesNetwork(Tier Two)Out-ofNetwork(Tier leWaived)50%90%90%(After Tier 1Deductible)50% 35 50Not ved)50% 20100%(DeductibleWaived) 30100%(DeductibleWaived)Not Applicable50% 250100%(DeductibleWaived) 250100%(DeductibleWaived) 250100%(DeductibleWaived)90%70%50%Emergency Services / Treatment:Urgent Care: Co-pay Per Visit(Waived If Admitted To Hospital ImmediatelyFollowing Visit) Paid By Plan After DeductibleWalk-In Retail Health Clinics: Co-pay Per Visit Paid By Plan After DeductibleEmergency Room / Emergency Physicians: Co-pay Per Visit Paid By PlanInpatient Admissions Through The EmergencyRoom: Paid By Plan After DeductibleExtended Care Facility Benefits Such As SkilledNursing, Convalescent Or Sub-Acute Facility: Maximum Days Per Calendar Year Paid By Plan After DeductibleGestational Diabetes Education: Co-pay Per Exam - Primary Care Physician Co-pay Per Exam - Specialist Paid By Plan After Deductible-5-90% 20 50100%(DeductibleWaived)60 Days90%(After Tier 1Deductible) 20 50100%(DeductibleWaived)50%Not ApplicableNot Applicable50%7670-00-410761
ParklandHealth &HospitalSystemNetwork(Tier One)Benefit PanelServicesNetwork(Tier Two)Out-ofNetwork(Tier 100%(DeductibleWaived)100%(DeductibleWaived) 2,000 Per ctibleWaived)90%90%(After Tier 1Deductible)50%Hospice Services: Paid By Plan After Deductible90%90%(After Tier 1Deductible)50%Bereavement Counseling: Paid By Plan After Deductible90%90%(After Tier leWaived)50%90%70%50%Hearing Services:Exams, Tests: Paid By PlanHearing Aids: Maximum Benefit Every 36 Months Paid By PlanImplantable Hearing Devices: Paid By PlanHome Health Care Benefits: Paid By Plan After DeductibleNote: A Home Health Care Visit Will Be ConsideredA Periodic Visit By Either A Nurse Or QualifiedTherapist, As The Case May Be, Or Up To Four (4)Hours Of Home Health Care Services.Hospice Care Benefits:Hospital Services:Pre-Admission Testing: Paid By Plan After DeductibleInpatient Services / Inpatient Physician ChargesRoom And Board Subject To The Payment Of SemiPrivate Room Rate Or Negotiated Room Rate: Paid By Plan After Deductible-6-7670-00-410761
ParklandHealth &HospitalSystemNetwork(Tier One)Benefit PanelServicesNetwork(Tier Two)Out-ofNetwork(Tier 0%70%50%90%70%50%Ovulation Induction With Ovulatory StimulantDrugs: Maximum Benefit Per Lifetime Paid By Plan After Deductible90%6 Courses Of Treatment70%50%Artificial Insemination: Maximum Benefit Per Lifetime Paid By Plan After Deductible90%6 Courses Of Treatment70%50% 20 50100%(DeductibleWaived) 20 50100%(DeductibleWaived)Not ApplicableNot Applicable50% 20100%(DeductibleWaived)Not ApplicableNot ApplicableNot Applicable50%Outpatient Services / Outpatient PhysicianCharges: Paid By Plan After DeductibleInpatient / Outpatient Or Hospital Setting Labs: Paid By Plan After DeductibleInpatient / Outpatient X-ray Charges In A HospitalSetting: Paid By Plan After DeductibleX-rays / Lab In An Independent Facility: Paid By Plan After DeductibleOutpatient Surgery / Surgeon Charges: Paid By Plan After DeductibleOutpatient Imaging Charges: Paid By Plan After DeductibleInfertility Treatment:Note: A Course Of Treatment Is One Cycle OfTreatment That Corresponds To One OvulationAttempt.Insulin Pump Education When Provided In TheOffice Setting: Co-pay Per Exam - Primary Care Physician Co-pay Per Exam - Specialist Paid By Plan After DeductibleManipulations: Co-pay Per Visit Paid By Plan After DeductibleNote: Medical Necessity Will Be Reviewed After 25Visits.-7-7670-00-410761
ParklandHealth &HospitalSystemNetwork(Tier One)Benefit PanelServicesNetwork(Tier %90%70%50%70%50%100%(DeductibleWaived)70%50% 50100%(DeductibleWaived)70%50%Inpatient Services / Physician Charges: Paid By Plan After Deductible90%70%50%Residential Treatment: Paid By Plan After Deductible90%70%50% 20100%(DeductibleWaived) 20100%(DeductibleWaived)Not Applicable50% 20100%(DeductibleWaived) 20100%(DeductibleWaived)Not Applicable50%Maternity:Routine Prenatal Services Paid By Plan After DeductibleNon-Routine Prenatal Services, Delivery AndPostnatal Care: Paid By Plan After DeductibleDelivery Facility (Tier 1 Benefit Will Only BeApplied For Those Who Participate In The UMRMaternity Management Program). : Co-pay Per Admission Paid By Plan After DeductibleDelivery Physician Services (Obstetrician, Surgeon,Anesthesiologist) (Tier 1 Benefit Will Only BeApplied For Those Who Participate In The UMRMaternity Management Program): Paid By Plan After DeductibleOutpatient Medically Necessary PregnancyTermination: Co-pay Per Exam Paid By Plan After DeductibleMental Health, Substance Use Disorder AndChemical Dependency Benefits:Outpatient Or Partial Hospitalization Services AndPhysician Charges: Co-pay Per Exam Paid By Plan After DeductibleOffice Visit: Co-pay Per Exam Paid By Plan After Deductible-8- 500100%(DeductibleWaived)Out-ofNetwork(Tier Three)7670-00-410761
Nutritional Counseling (Received Other ThanParkland Or UT Southwestern St. Paul Hospital): Maximum Benefit Per Visit Paid By Plan After In Network DeductibleNutritional Counseling And Diabetic EducationalTraining Received At Parkland, UT SouthwesternSt. Paul Hospital, Or Children’s Hospital: Co-Pay Per Visit Paid By PlanOrthotic Appliances: Paid By Plan After DeductibleOutpatient Dialysis: Paid By Plan After DeductiblePhysician Office Visit:Primary Care Physician Office Visit: Co-pay Per Exam Paid By Plan After DeductibleSpecialist Office Visit: Co-pay Per Exam Paid By Plan After DeductiblePhysician Office Services: Paid By Plan After DeductiblePreventive / Routine Care Benefits. See GlossaryOf Terms For Definition. Benefits Include:Preventive / Routine Physical Exams AtAppropriate Ages: Paid By Plan After DeductibleImmunizations: Paid By Plan After DeductiblePreventive / Routine Diagnostic Tests, Lab AndX-rays At Appropriate Ages: Paid By Plan After Deductible-9-ParklandHealth &HospitalSystemNetwork(Tier One)Benefit PanelServicesNetwork(Tier Two)Out-ofNetwork(Tier Three)90% 16090%90% 20100%(DeductibleWaived) 20100%(DeductibleWaived) 20100%(DeductibleWaived)90%90%(After Tier 1Deductible)50%90%70% 20100%(DeductibleWaived) 30100%(DeductibleWaived)Not Applicable50% 50100%(DeductibleWaived) 50100%(DeductibleWaived)Not %No Benefit7670-00-410761
Preventive / Routine Mammograms And BreastExams: Maximum Exams Per Calendar Year Paid By Plan After DeductibleParklandHealth &HospitalSystemNetwork(Tier One)Benefit PanelServicesNetwork(Tier Two)100%(DeductibleWaived)1 Exam100%(DeductibleWaived)100%(DeductibleWaived)1 Exam100%(DeductibleWaived)100%(DeductibleWaived)2 tibleWaived)50%100%(DeductibleWaived)1 Exam100%(DeductibleWaived)Out-ofNetwork(Tier Three)50%Note: 3D Mammograms Are Covered.Preventive / Routine Pap Test: Maximum Exams Per Calendar Year Paid By Plan After DeductiblePreventive / Routine Pelvic Exams: Maximum Exams Per Calendar Year Paid By Plan After DeductiblePreventive / Routine PSA Test and Prostate Exams:From Age 40 (Or Earlier If Recommended By APhysician Due To Positive Family History) Paid By Plan After DeductiblePreventive / Routine Screenings / Services AtAppropriate Ages And Gender: Paid By Plan After DeductiblePreventive / Routine Autism Screening:From Age 0 To 21 Paid By Plan After DeductiblePreventive / Routine Colonoscopy, SigmoidoscopyAnd Similar Routine Surgical Procedures Done ForPreventive Reasons: Paid By Plan After DeductiblePreventive / Routine Hearing Exams: Maximum Exams Per Calendar Year Paid By Plan After Deductible-10-50%50%50%7670-00-410761
ParklandHealth &HospitalSystemNetwork(Tier One)Benefit PanelServicesNetwork(Tier hese Services May Also Apply To Men.Private Duty Nursing: Paid By Plan After Deductible90%50%Prosthetic Devices: Paid By Plan After Deductible90%(After Tier 1Deductible)90%50%Sleep Studies / Sleep Disorders: Paid By Plan After Deductible90%(After Tier 1Deductible)90%90%(After Tier 1Deductible)50%Alcohol And Substance Use Disorder, TobaccoUse, Obesity, Diet and Nutritional Counseling: Paid By Plan After DeductibleIn Addition, The Following Preventive / RoutineServices Are Covered For Women: Gestational Diabetes Papillomavirus DNA Testing Counseling For Sexually TransmittedInfections (Provided Annually)* Counseling For Human Immune-DeficiencyVirus (Provided Annually)* Breastfeeding Support, Supplies, AndCounseling Counseling For Interpersonal And DomesticViolence For Women (Provided Annually)* Paid By Plan After Deductible-11-Out-ofNetwork(Tier Three)7670-00-410761
Sterilizations:For Men: Paid By Plan After DeductibleFor Women: Paid By Plan After DeductibleTeladoc Services:ParklandHealth &HospitalSystemNetwork(Tier One)Benefit PanelServicesNetwork(Tier Two)Out-ofNetwork(Tier leWaived)50%General Medicine: Co-pay Per Occurrence Paid By Plan 24100% (Deductible Waived)Note: Multiple Co-pays Apply When MultipleClaims Are Billed On The Same Date Of Service.Temporomandibular Joint Disorder Benefits: Paid By Plan After DeductibleTherapy Services:Occupational / Physical Outpatient Hospital AndOffice Therapy: Co-pay Per Exam Paid By Plan After DeductibleSpeech Outpatient Hospital And Office Therapy: Co-pay Per Exam Paid By Plan After DeductibleNote: Medical Necessity Will Be Reviewed After 25Visits.Wigs, Toupees Or Hairpieces Related To CancerTreatment And Alopecia Areata: Maximum Benefit Per Calendar Year Paid By Plan After DeductibleAll Other Covered Expenses: Paid By Plan After Deductible-12-90%70%50% 20100%(DeductibleWaived) 50100%(DeductibleWaived)Not Applicable50% 20100%(DeductibleWaived) 20100%(DeductibleWaived)Not Applicable50%90%1 Wig90%50%90%70%50%7670-00-410761
TRANSPLANT SCHEDULE OF BENEFITSBenefit Plan(s) 001Transplant Services: Designated TransplantFacility:Transplant Services For Kidney And PancreaticTransplants: Paid By Plan After Deductible60%Transplant Services For All Other Transplants: Paid By Plan After Deductible90%Travel And Housing: Maximum Benefit Per Person Per Night ForLodging Maximum Benefit Per Transplant Paid By PlanTravel And Housing At Designated Transplant FacilityAt Contract Effective Date/Pre-Transplant EvaluationAnd Up To One Year From Date Of Transplant. 50 10,000100% (Deductible Waived)ParklandHealth &HospitalSystemNetwork(Tier One)Benefit PanelServicesNetwork(Tier Two)Out-ofNetwork(Tier Three)Transplant Services For Kidney And PancreaticTransplants: Paid By Plan After Deductible90%60%60%Transplant Services For All Other Transplants: Paid By Plan After Deductible90%90%50%Transplant Services: Non-Designated TransplantFacility:-13-7670-00-410761
PRESCRIPTION SCHEDULE OF BENEFITSAdministered By MEDIMPACTBenefit Plan(s) 001GenericPreferred BrandRetail Pharmacies (up to 30 day supply)Specified Parkland On-site 10 copay 20 copayPharmaciesWalgreens Pharmacies * 20 copay 45 copayMedImpact Broad Network40% coinsurance40% coinsurance(Min 30/Max 45)(Min 75/Max 125)Out of Network100%100%Mail Order Pharmacy (90 day supply)Parkland Mail Order 25 copay 50 copayMed Direct Mail Order 50 copay 115 copayAnnual Out of Pocket Maximum(Plan pays 100% of Rx cost once the out of pocket maximum has been met)Per Person 2,500Per Family 6,000Non-PreferredBrand 40 copay 75 copay50% coinsurance(Min 100/Max 175)100% 100 copay 190 copay* 90-day supply available at Walgreens retail pharmacy. Cost is 3 times the cost of a 30-day supply.Specialty Drug Program – All specialty drugs must be obtained through Parkland’s pharmacies or theMedImpact Choice Specialty Network. The benefits for the specialty drug program are outlined in thetable below:Specialty Drug BenefitWhat the Member Will Pay for Fill of a 30-Day SupplySpecialty Drug TierParkland PharmacyNon-Parkland Pharmacy(MedImpact Choice SpecialtyNetwork)Tier 120% coinsurance up to a maximum of 25% coinsurance up to a maximum 100of 150Tier 235% coinsurance up to a maximum of 40% coinsurance up to a maximum 300of 350Tier 340% coinsurance up to a maximum of 50% coinsurance up to a maximum 500of 600Out of Network100%100%-14-7670-00-410761
INCENTIVE SOLUTIONSYou may be offered incentive rewards to encourage You to participate in various health and wellnessprograms or healthy activities. The decision about whether or not to participate is Yours alone, andDALLAS COUNTY HOSPITAL DISTRICT d/b/a PARKLAND HEALTH & HOSPITAL SYSTEMrecommends that You discuss participating in such programs with Your Physician. For additionalinformation and answers to questions concerning incentives, please contact Your Human Resources orPersonnel office.-15-7670-00-410761
OUT-OF-POCKET EXPENSES AND MAXIMUMSCO-PAYSA Co-pay is the amount that the Covered Person must pay to the provider each time certain services arereceived. Co-pays do not apply toward satisfaction of Deductibles or out-of-network out-of-pocketmaximums. The Co-pay and out-of-pocket maximum are shown on the Schedule of Benefits.DEDUCTIBLESDeductible refers to an amount of money paid once a Plan Year by the Covered Person before anyCovered Expenses are paid by this Plan. A Deductible applies to each Covered Person up to a familyDeductible limit. When a new Plan Year begins, a new Deductible must be satisfied.Deductible amounts are shown on the Schedule of Benefits.Pharmacy expenses do not count toward meeting the Deductible of this Plan. The Deductible amountsthat the Covered Person incurs for Covered Expenses will be used to satisfy the Deductible(s) shown onthe Schedule of Benefits.(Applies to Tier One and Tier Two) The Deductible amounts that the Covered Person incurs at TierOne and Tier Two benefit levels will be used to satisfy the Tier One and Tier Two benefit level’s totalindividual and family Deductible.(Applies to Tier Three) The Deductible amounts that the Covered Person incurs at an out-of-networkprovider will apply to the out-of-network total individual and family Deductible only.If You have family coverage, any combination of covered family members can help meet the maximumfamily Deductible, up to each person’s individual Deductible amount.PLAN PARTICIPATIONPlan Participation means that, after the Covered Person satisfies the Deductible, the Covered Person andthe Plan each pay a percentage of the Covered Expenses until the Covered Person’s (or family’s, ifapplicable) annual out-of-pocket maximum is reached. The Plan Participation rate is shown on theSchedule of Benefits. The Covered Person will be responsible for paying any remaining charges due tothe provider after the Plan has paid its portion of the Covered Expense, subject to the Plan’s maximumfee schedule, Negotiated Rate, or Usual and Customary amounts as applicable. Once the annual out-ofpocket maximum has been satisfied, the Plan will pay 100% of the Covered Expense for the remainder ofthe Plan Year.Any payment for an expense that is not covered under this Plan will be the Covered Person’sresponsibility.ANNUAL OUT-OF-POCKET MAXIMUMS(Applies to Tier One and Tier Two) The annual out-of-pocket maximum is shown on the Schedule ofBenefits. Amounts the Covered Person incurs for Covered Expenses, such as the Deductible, Co-pays ifapplicable, and any Plan Participation expense, will be used to satisfy the Covered Person’s (or family’s,if applicable) annual in-network out-of-pocket maximum(s). Pharmacy expenses that the Covered Personincurs apply toward the out-of-pocket maximum of this Plan.(Applies to Tier Three) The annual out-of-pocket maximum is shown on the Schedule of Benefits.Amounts the Covered Person incurs for Covered Expenses, such as the Deductible, Co-pays ifapplicable, and any Plan Participation expense, will be used to satisfy the Covered Person’s (or family’s,if applicable) annual in-network out-of-pocket maximum(s). Pharmacy expenses that the Covered Personincurs do not apply toward the medical out-of-pocket maximum of this Plan.-16-7670-00-410761
The following will not be used to meet the out-of-pocket maximums: (Applies to Tier Three) Out-of-network Co-pays.Penalties, legal fees and interest charged by a provider.Expenses for excluded services.Any charges above the limits specified elsewhere in this document.(Applies to Tier Three) Out-of-network Individual and family Deductibles will not be used to meetthe out-of-network out-of-pocket maximum.Expenses Incurred as a result of failure to comply with prior authorization requirements.Any amounts over the Usual and Customary amount, Negotiated Rate or established fee schedulethat this Plan pays.(Applies to Tier One and Tier Two) The eligible out-of-pocket expenses that the Covered Person incursat Tier One and Tier Two benefit levels will be used to satisfy the Tier One and Tier Two total out-ofpocket maximum.(Applies to Tier Three) The eligible out-of-pocket expens
DISTRICT d/b/a PARKLAND HEALTH & HOSPITAL SYSTEM . DALLAS TX. Health Booklet Revised 01-01-2022 . . Name, Address And Phone Number Of Plan Administrator : DALLAS COUNTY HOSPITAL DISTRICT d/b/a PARKLAND HEALTH & HOSPITAL SYSTEM 5200 HARRY HINES BLVD . BENEFITS DEPARTMENT - BLDG B :
