Page 103 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

regardless of whether the cost of providing or arranging to provide the Covered Person's health
care is less than or more than the payment.

• Bundled payments - certain Network providers receive a bundled payment for a group of Covered
Health Care Services for a particular procedure or medical condition. Your Copayment and/or
Coinsurance will be calculated based on the provider type that received the bundled payment. The
Network providers receive these bundled payments regardless of whether the cost of providing or
arranging to provide the Covered Person's health care is less than or more than the payment. If
you receive follow-up services related to a procedure where a bundled payment is made, an
additional Copayment and/or Coinsurance may not be required if such follow-up services are
included in the bundled payment. You may receive some Covered Health Care Services that are
not considered part of the inclusive bundled payment and those Covered Health Care Services
would be subject to the applicable Copayment and/or Coinsurance as described in your Schedule
of Benefits.

The Claims Administrator uses various payment methods to pay specific Network providers. From time to
time, the payment method may change. If you have questions about whether your Network provider's
contract with the Claims Administrator includes any financial incentives, the Claims Administrator
encourages you to discuss those questions with your provider. You may also call the Claims
Administrator at the telephone number on your ID card. The Claims Administrator can advise whether
your Network provider is paid by any financial incentive, including those listed above; however, the
specific terms of the contract, including rates of payment, are confidential and cannot be disclosed.

Are Incentives Available to You?

Sometimes the Claims Administrator may offer coupons, enhanced Benefits, or other incentives to
encourage you to take part in various programs, including wellness programs or certain disease
management programs, surveys, discount programs and/or programs to seek care in a more cost
effective setting and/or from Designated Providers. In some instances, these programs may be offered in
combination with a non-UnitedHealthcare entity. The decision about whether or not to take part in a
program is yours alone. However, you should discuss taking part in such programs with your Physician.
Contact the Claims Administrator at www.myuhc.com or the telephone number on your ID card if you
have any questions.

Does the Claims Administrator Receive Rebates and Other
Payments?

The Plan Sponsor and the Claims Administrator may receive rebates for certain drugs that are
administered to you in your home or in a Physician's office, or at a Hospital or Alternate Facility. This
includes rebates for those drugs that are administered to you before you meet any applicable deductible.
The Plan Sponsor and the Claims Administrator may pass a portion of these rebates on to you. When
rebates are passed on to you, they may be r taken into account in determining your Copayments or
Coinsurance.

Who Interprets Benefits and Other Provisions under the Plan?
The Plan Sponsor and the Claims Administrator have the sole and exclusive discretion to do all of the
following:
• Interpret Benefits under the Plan.

• Interpret the other terms, conditions, limitations and exclusions set out in the Plan, including this
SPD, the Schedule of Benefits and any Summary Material Modifications (SMM), and/or
Amendments.
• Make factual determinations related to the Plan and its Benefits.

100 Section 8: General Legal Provisions