Page 20 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Covered Health The Amount You Pay The Amount You Pay What are the Limitations
Care Service Network Out-of-Network & Exceptions?
purchase, rent or obtain the
DME from the vendor the
Claims Administrator
identifies or purchase it
directly from the prescribing
Network Physician.

Does the Amount Network Yes
You Pay Apply to
the Out-of-Pocket Yes
Limit?

Does the Annual Network Yes
Deductible Apply?
Yes
Emergency Health Care Services - Outpatient

What Is the 20% after you pay Emergency: Note: If you are confined in
Copayment or $150 copayment per an out-of-Network Hospital
Coinsurance You visit 20%, after you pay after you receive outpatient
Pay? This May $150 copayment per Emergency Health Care
Include a visit Services, you must notify
Copayment, Non-Emergency: the Claims Administrator
Coinsurance or within one business day or
Both. 40%, after you pay on the same day of
$150 copayment per admission if reasonably
visit possible. The Claims
Administrator may elect to
transfer you to a Network
Hospital as soon as it is
medically appropriate to do
so. If you choose to stay in
the out-of-Network Hospital
after the date the Claims
Administrator decides a
transfer is medically
appropriate, Network
Benefits will not be
provided. Out-of-Network
Benefits may be available if
the continued stay is
determined to be a Covered
Health Care Service.
If you are admitted as an
inpatient to a Hospital
directly from the Emergency
room, the Benefits provided
as described under Hospital
- Inpatient Stay will apply.
You will not have to pay the
Emergency Health Care
Services Copayment.

17 Schedule of Benefits Plan Set 008