Page 9 - 2020 McLennan County Benefits Enrollment Guide

How do I appeal a decision that adversely affects coverage, benefits or my
relationship with the organization?

For more information on your appeal rights, please contact Customer Advocacy by calling 1-800-321-7947.

How are injections charged under my plan?
The codes the providers use determines how the benefits pay. If the provider sees the injection as more of a diagnostic
procedure then you may be subject to paying deductible and co-insurance.

What kind of coverage will my college-age child have while away at school?
The McLennan County Employee Health Plan will cover any emergency that occurs while away at school with any
applicable deductibles or out-of-pocket maximums; however, it is important to plan for routine medical needs. Out-of-
network may be subject to balance billing. If your child is attending school within the state and is located near an in-
network clinic, your child can receive covered care at the facility. If the student is attending school out of the service
area, it may be necessary to consider supplementary coverage for routine medical care or consider using the college
health center for his/her routine medical care.

How do I get a referral outside the network when you cannot provide the services
that I need?

The provider network is a large multi-specialty network and, in most cases, can meet the majority of your medical needs.
If you develop a medical condition that your regular doctor and the network specialists cannot care for, you will need (1)
a recommendation from your network provider; and (2) the approval of the Medical Director before any out-of-plan
services can be covered. A formal review of your case will then be provided and you will receive a letter outlining clearly
what the McLennan County Employee Health Plan will or will not cover with the outside physician.

Health Care Plan Information & Terminology

In-Network Advantage
When you use an in-network provider, the percentage you pay out-of-pocket will be based on a negotiated fee, which is
usually lower than the actual charges. Coverage may only be provided for an out-of-network provider if there is a
qualifying emergency. If you use a provider who is outside of the network, you may be responsible for paying the
difference between the allowable charges and what the provider charges. Allowable amounts are set by Scott & White;
allowable amounts are generally considered reasonable based on what most providers charge for a particular service in
a geographic area. Any charges above the allowable amount will not count toward your deductible or out-of-pocket
max.

Annual Deductible
Your annual deductible is the amount of money you must first pay out-of-pocket before your plan begins paying for
services covered by coinsurance. With some services from an out-of-network provider, the plan pays a lower
percentage of coinsurance. The deductible starts over every January 1. Refer to your health care plan summaries for
more information. In many cases, the deductible does not need to be met for services when a copay applies.

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