Medical

How the Plan Works

The Health Fund provides comprehensive medical care, including preventive care, with no out-of-pocket costs. With the HealthMate Coast-to-Coast plan, you can use any provider (for example, a doctor, hospital, or lab) you wish. However, when you use in-network providers, you’ll pay less for care.

Blue Cross & Blue Shield of Rhode Island administers the plan, but the money to pay claims comes from you and your contributing employer. Learn about who really pays benefits when you have a medical claim.

Highlights

* Annual in-network deductible does not apply to preventive care, services with a copayment, prescription drugs, diagnostic testing, or outpatient mental health and substance use disorder services.

Who really pays benefits when you have a medical claim?

Our medical and prescription drug (Rx) plans are self-funded. This means the Fund uses an insurance company—Blue Cross & Blue Shield of Rhode Island—to give you access to lower-cost, in-network doctors, hospitals, and pharmacies. Blue Cross also administers our medical and Rx benefits claims.

The money to pay claims does not come from Blue Cross & Blue Shield of Rhode Island. It comes from the income generated by contributions (made on your behalf) from participating employers to the Fund. This means the Health Fund takes on all the financial responsibility of providing your medical and Rx coverage and paying benefits:

1. Each year, medical and Rx benefit payments for members could be lower than expected. If so, the Health Fund saves money. The savings stay in the Fund, making the Fund stronger financially.
2. However, each year, benefit payments for members could be higher than expected. If so, the Health Fund pays money from its financial reserves to cover the higher costs.

No Surprises Act

The federal government’s No Surprises Act took effect January 1, 2022. This law protects you from balance billing if you are treated by an out-of-network provider when you’re at an in-network hospital or emergency room. Balance billing is when an out-of-network provider requires you to pay the difference between the total cost of your care and what your health plan agreed to pay.

Sometimes, in-network emergency rooms and hospitals employ out-of-network doctors. In these cases, you might receive care from an out-of-network provider through no fault of your own. Also, you might not have time to choose between using an in- or out-of-network provider in a medical emergency. The No Surprises Act is designed to ensure that you aren’t balance billed if you receive care under these circumstances. It protects you from paying extra when the circumstances are beyond your control.

You should still use network providers whenever possible. Visit Blue Cross & Blue Shield of Rhode Island to find network providers near you.

If you believe you’ve been balance billed when you shouldn’t have, contact the Employee Benefits Security Administration (EBSA) at 866-444-3272 or through their website.

The above summary is not a complete description of the rules under the No Surprises Act. Please also read this important notice about your rights under the No Surprises Act.

Note: Information about the implementation of the federal government’s health care price transparency rule will be provided in the future.