Page 101 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Section 8: General Legal Provisions

What Is Your Relationship with the Claims Administrator and Plan
Sponsor?

It is important for you to understand the Claims Administrator's role with respect to the Plan and how it
may affect you. The Claims Administrator helps administer the claims payment for the Plan Sponsor's
Plan in which you are enrolled. The Claims Administrator and the Plan Sponsor do not provide medical
services or make treatment decisions. This means:
• The Claims Administrator communicates to you decisions about whether the Plan will cover or pay
for the health care that you may receive. The Plan pays for Covered Health Care Services, which
are more fully described in this SPD.

• The Plan may not pay for all treatments you or your Physician may believe are needed. If the Plan
does not pay, you will be responsible for the cost.

The Plan Sponsor and the Claims Administrator may use individually identifiable information about you to
identify for you (and you alone) procedures, products or services that you may find valuable. The Plan
Sponsor and the Claims Administrator will use individually identifiable information about you as permitted
or required by law, including in the Claims Administrator's operations and in the Claims Administrator's
research. The Plan Sponsor and the Claims Administrator will use de-identified data for commercial
purposes including research.
Please refer to the Claims Administrator's Notice of Privacy Practices for details.

What Is the Claims Administrator's Relationship with Providers and
Plan Sponsors?

The Claims Administrator has agreements in place that govern the relationships between it and Plan
Sponsors and Network providers, some of which are affiliated providers. Network providers enter into
agreements with the Claims Administrator to provide Covered Health Care Services to Covered Persons.

Plan Sponsors and the Claims Administrator do not provide health care services or supplies, or practice
medicine. Plan Sponsors and the Claims Administrator arrange for health care providers to participate in
a Network and the Claims Administrator processes the Plan's payment of Benefits. Network providers are
independent practitioners who run their own offices and facilities. The Claims Administrator's credentialing
process confirms public information about the providers' licenses and other credentials. It does not assure
the quality of the services provided. Network providers are not the Plan Sponsor's employees. Network
providers are not the Claims Administrator's employees. The Plan Sponsor and the Claims Administrator
are not responsible for any act or omission of any provider.
The Claims Administrator is not considered to be an employer for any purpose with respect to the
administration or provision of benefits under the Plan Sponsor's Plan. The Claims Administrator is not
responsible for fulfilling any duties or obligations of an employer with respect to the Plan Sponsor's Plan.

The Plan Sponsor is solely responsible for all of the following:
• Enrollment and classification changes (including classification changes resulting in your enrollment
or the termination of your coverage).
• The timely payment of the Plan's Service Fee to the Claims Administrator.

• The funding of Benefits on a timely basis.
• Notifying you of when the Plan ends.

98 Section 8: General Legal Provisions