Page 102 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

When the Plan Sponsor establishes the Plan to provide coverage under a benefit plan governed by the
Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. §1001 et seq., the Claims Administrator
is not the plan administrator or named fiduciary of the benefit plan, as those terms are used in ERISA. If
you have questions about your welfare benefit plan, you should contact the Plan Sponsor. If you have any
questions about this statement or about your rights under ERISA, contact the nearest area office of the
Employee Benefits Security Administration, U. S. Department of Labor.

What Is Your Relationship with Providers and Plan Sponsors?
The relationship between you and any provider is that of provider and patient.

You are responsible for all of the following:
• Choosing your own provider.

• Paying, directly to your provider, any amount identified as a participant responsibility, including
Copayments, Coinsurance, any deductible and any amount that exceeds the Allowed Amount.

• Paying, directly to your provider, the cost of any non-Covered Health Care Service.
• Deciding if any provider treating you is right for you. This includes Network providers you choose
and providers that they refer.
• Deciding with your provider what care you should receive.

Your provider is solely responsible for the quality of the services provided to you.
The relationship between you and the Plan Sponsor is that of employer and employee, Dependent or
other classification as defined in the Plan.

Notice

When the Claims Administrator provides written notice regarding administration of the Plan to an
authorized representative of the Plan Sponsor, that notice is deemed notice to all affected Participants
and their Enrolled Dependents. The Plan Sponsor is responsible for giving notice to you.

Statements by the Plan Sponsor or Participants

All statements made by the Plan Sponsor or by a Participant shall, in the absence of fraud, be deemed
representations and not warranties. The Claims Administrator will not use any statement made by the
Plan Sponsor to void the Plan after it has been in force for two years unless it is a fraudulent statement.

Does the Claims Administrator Pay Incentives to Providers?
The Claims Administrator pays Network providers through various types of contractual arrangements.
Some of these arrangements may include financial incentives to promote the delivery of health care in a
cost efficient and effective manner. These financial incentives are not intended to affect your access to
health care.
Examples of financial incentives for Network providers are:

• Bonuses for performance based on factors that may include quality, member satisfaction and/or
cost-effectiveness.

• Capitation - a group of Network providers receives a monthly payment from the Claims
Administrator for each Covered Person who selects a Network provider within the group to perform
or coordinate certain health care services. The Network providers receive this monthly payment

99 Section 8: General Legal Provisions