Frequently Asked Questions

The Health and Welfare Fund is administered jointly by a 14-person Board of Trustees made up of an equal number of Union and Employer appointees. The Trustees are not compensated for the performance of their duties and have the full power and authority to administer the Plan, construe the terms and provisions and to establish all Plan rules and regulations. The Trustees employ an Executive Director to perform all day to day administrative functions of the Plan.

The I.A.T.S.E. National Health and Welfare Fund Plan A was initially established in 1973.

You are a participant in Plan A if your employer contributes to Plan A and you are eligible under the Plan A rules. Participants of Plan A generally work in the live theatre industry under Collective Bargaining Agreements between I.A.T.S.E. and Theatrical Producers, such as the Travelling Employees (or “Pink Contract).

The Collective Bargaining Agreements determine the employer contribution rate for each day of your covered employment. However, the employer must meet the minimum daily contribution rate established by the Trustees. The Plan is supported by employer contributions; employees cannot contribute to Plan A.

You must work in “covered employment" and work a minimum of 60 days in a six month period to qualify for coverage under Plan A.

Your coverage begins the first of the month following the second month in which you work a minimum of 60 days in Covered Employment within six months or less. For example, if you work 60 days in Covered Employment in the six-month period ending November 30th, your coverage will start January 1st.

Yes, your spouse and unmarried dependent children up to the age limit of the Plan, currently the end of the year in which they turn age 26, become eligible when you do. See the Health and Welfare Plan A Summary Plan Description for more information about eligible dependents.

Plan A coverage is granted in six-month blocks. At the end of your six-months of coverage, the Fund Office will look back at the six-month eligibility period ending one month prior to the look back date. For example, if you earned eligibility for coverage January 1 to June 30, the Fund Office would look back at the six-months December 1 through May 31 to see if you worked at least 60 days in Covered Employment. If you meet the 60-day requirement, your coverage continues for another six months.

Plan A benefits available to eligible participants and their eligible dependents are hospital/medical, prescription drug, dental, vision, and hearing aid benefits. In addition, eligible participants, but not dependents, are covered for life insurance and weekly accident and sickness benefits.

The Health and Welfare Fund is administered jointly by a 14-person Board of Trustees made up of an equal number of Union and Employer appointees. The Trustees are not compensated for the performance of their duties and have the full power and authority to administer the Plan, construe the terms and provisions and to establish all Plan rules and regulations. The Trustees employ an Executive Director to perform all day to day administrative functions of the Plan.

The I.A.T.S.E. National Health and Welfare Fund Plan C was initially established in 1994.

In order to qualify to enroll in a Health Reimbursement Arrangement (HRA), which is what the National Health and Welfare Fund’s MRP is, you must have primary health coverage that is a group plan sponsored by an employer (that is, obtained through employment) or sponsored by a union. Your primary health coverage cannot be “individual” coverage for this purpose.

Individual coverage is coverage that you purchase on your own (whether directly from an insurance carrier, such as Cigna, Aetna, United, BlueCross or BlueShield, or through a state insurance Marketplace (previously called the “Exchange” such as in the state of Massachusetts) or that you obtain through a government program such as Medicare, Medicaid, Veterans Administration, National Programs (such as the U.K.) etc.

Guidance was issued by the government on September 13, 2013 which dictated that, in order for someone to enroll in an HRA (like the MRP Plan), they must be actually enrolled in an employer/union sponsored group health plan. The National Health & Welfare Fund must comply with this legal requirement.

As far as we understand, there is no prohibition on purchasing coverage through the Health Insurance Marketplace even if a person has other health coverage. However, if you have coverage under the Fund (or an offer to opt into coverage), you may be disqualified from receiving a federal subsidy for coverage purchased through the Marketplace.

No. In order to enroll in the stand-alone MRP Plan, your other coverage must be employer or union sponsored group health coverage.

No. These are not employer/union sponsored plans and are therefore not considered acceptable other coverage for enrollment in the Fund’s MRP stand-alone option pursuant to ACA guidance.

If you have stopped working (retired) and you have a Plan C CAPP balance, you can enroll in the Retiree Medical Reimbursement Program (R-MRP). See the Retiree MRP Plan Summary Plan Description for specific rules. Your Medicare coverage(s) will be your primary coverage.

If you are still working, even sporadically, and your employer contributions in a quarter (plus your balance) equals or exceeds the Plan’s current cost of C4 Single, the you must, in accordance with CMS (Medicare) rules, enroll in Plan coverage and your Medicare coverage(s) will be secondary coverage.

Yes. Any group health plan coverage obtained through your employment or employment of your spouse or partner is acceptable “other group health coverage” for purposes of enrollment in the stand-alone MRP Plan, provided that you submit the required proof of other coverage and certify that the other coverage meets the ACA’s minimum value standard. You can check with your Plan Sponsor (typically your employer) or the insurance carrier whether the other coverage meets the minimum value standard. All benefit funds and insurance companies are required to issue SBCs (Summary of Benefits and Coverage) that indicate whether the plan of benefits meets the minimum value standard pursuant to the ACA’s requirements. The SBC will indicate that at the top of the form.

Annually, you must provide the following:

 (1) front and back copy of your other employer or union sponsored group health coverage ID card which clearly states GROUP coverage on the card.

 (2) OR, a letter from your Plan-sponsor stating you are enrolled in an employer or union sponsored group health plan that meets the Affordable Care Act (ACA) minimum value standard

 (3) The signed certification that comes with your annual open enrollment statement

 (4) If you are enrolling on-line via the Fund website, there is an on-line certification that you electronically sign, and you can upload your ID card or your plan sponsor letter.

No! You may not waive coverage under the Fund’s Plan C1, C2, C3, C4 or Triple S options.

No. You must incur the claim while enrolled in MRP AND reimbursement can only be made if you are enrolled in the MRP Plan at the time the claim is received.

If you incurred the claim while enrolled in the MRP Plan and submit it while you are in active coverage but you have excess balance available for reimbursement, you have 12 months from the date of service to submit the claim or if incurred with excess balance available and submitted when enrolled in MRP or with a continuing excess balance, you have 12 months from the date of service to submit that claim for reimbursement.

12 months from the date of service.

As long as your period of being uninsured is less than three (3) months and only occurs once in a calendar year then the IRS will not impose a penalty on you. Since the Health Fund’s coverage runs in quarters, a loss of coverage will be equal to, and in some cases greater than, three months. Therefore, to avoid a tax penalty you should exercise your right to obtain coverage through COBRA (by making a timely election and payment) or purchase coverage through the Health Insurance Marketplace.

In general, the ACA’s minimum value requirement means that your other employer or union sponsored group health coverage plan pays at least 60% of the total cost of medical services coverage by that plan.

Affordable means that any payment you make for your individual coverage only (excluding any cost to cover your dependents) cannot exceed 9.5% of your total household income. Since the Fund does not maintain information about your total income or that of your entire household we would be unable to guide you as to whether or not coverage through one of our Plan options or that of another group fits the government’s definition of affordable.

Plan C participants usually work in the Motion Picture, Television, Commercial and Trade show industries under Collective Bargaining Agreements with I.A.T.S.E. or an affiliated Local that require employer contributions to Plan C.

The Collective Bargaining Agreements describe the employer contribution rate for each unit (day, week, month, or hour) of your covered employment. Some agreements require employer contributions on a percentage of your wages.

Yes, except for the first $150 of employer contributions when you begin to work under a Plan C Collective Bargaining Agreement. Thereafter, contributions made by your employer when you work in covered employment go into your CAPP (Contributions Available for Premium Payments) account. Your CAPP account is central to your eligibility and serves as the payment mechanism for your Plan C benefits.

Yes, Plan C currently hosts five (5) different coverage options plus Triple S for our Puerto Rico residents. Eligible participants can choose from C1, C2, C3, C4 or the stand alone Medical Reimbursement options. All offerings are made with a single (participant only) or family (2 or more eligible family members) rate. Our Benefits at a Glance provides a side-by-side description of each option.

New employees who have never participated in Plan C before may voluntarily enroll in Plan C once their CAPP account has enough employer contributions to meet the charge for one month of Plan C-2 individual coverage. Please note that this is after the first $150 of employer contributions for new employees is applied to the Health and Welfare Fund’s general assets.

Yes, since Plan C coverage is financed by your individual CAPP account, the charge for family enrollment is greater than for individual enrollment.

Yes, if, when you reach either the voluntary or automatic enrollment thresholds and you demonstrate to the Fund Office that you have other employer or union sponsored group health coverage that meets the minimum value standards of the Affordable Care Act (ACA) you can use your CAPP account for the Plan C medical reimbursement program. Please remember there is a quarterly $60 administrative fee and you must provide proof of qualifying other coverage EVERY year along with a signed certification of the ACA requirements by the open enrollment deadline which is typically December 15th to remain enrolled in this coverage option for the next calendar quarter.

Your coverage will be automatically downgraded to the next lower level of coverage if you do not make any applicable co-payment provided there is enough money in your account to do so. You may risk losing valuable family coverage if your account balance only supports single coverage. If there is not enough money in your account to be downgraded your coverage will lapse which means your coverage terminates. You will only be allowed to continue coverage through the COBRA self-payment provision of the Plan. In order to return to coverage you will need to first meet the $150 administrative fee and then your account balance must reach one month of the current cost C3 single Please see CAPP rates for the applicable amount as these rates may change from time to time.

Due to provisions of the Patient Protection and Affordable Care Act (ACA) that limited the ability of individuals to participate in Plan C’s stand-alone Medical Reimbursement Program (MRP) under certain circumstances, numerous participants and Local Unions sought a lower cost alternative to Plans C1, C2, and C3.

Yes, Plan C4 is a high deductible plan that provides minimum value coverage in accordance with the ACA. C4 benefits include hospital, medical/surgical, and prescription drugs (all essential benefits). In addition, all required well care services are included with no cost sharing, and the out-of-pocket limit (this will be described in more detail later in this memorandum) meets the ACA’s requirements.

The current quarterly cost for single coverage is $ 902.00. The quarterly cost for a family plan is currently $ 1,737.00. These costs are approximately 20% less than the current C3 cost. CAPP charges may change so please check with the Fund Office for current CAPP charges.

All open enrollment election coupons and any applicable co-payment, must be received at the Fund Office Lockbox no later than December 15th (or the next business day if it falls on a weekend) preceding the January 1st coverage quarter.

Yes, each quarter the Fund Office sends a statement showing a participant’s available CAPP balance in advance of the prospective coverage quarter. Downgrading to a lower level coverage in Plan C is always permissible for a future coverage quarter. However, a participant cannot switch to a higher level of coverage except at each annual open enrollment unless there is a life event such as the birth of a child, adoption of a child, marriage or divorce. Please review the Plan’s Summary Plan Description booklet further for a description of such life events.

• C4 is an EPO, Exclusive Provider only Plan.

• C4 is a high deductible plan with an annual deductible of $3,000 per individual and $7,500 per family. Once the deductible has been met (the participant or another family member has paid the first $3,000 per person, or $7,500 for the family, of covered in-network services) then the Plan will pay 50% of covered expenses. (Plan pays 50%, patient pays 50% for covered expenses up to the out of pocket maximum amount for that year).

• Covered in-network benefits for hospital, medical (doctor visits, laboratory, and radiology), , surgery, etc. will be provided by Empire BlueCross BlueShield. Prescription benefits will be provided by CVS/Caremark. Certain services have a co-payment (a flat dollar payment that the patient pays to the provider at the time of the service) and are not subject to the co-insurance (50% cost sharing) such as emergency room visits.

• Annually, the first three (3) primary care visits per covered family member are reimbursable at 100% for an in-network provider. The deductible and co-insurance will apply at the fourth (4th) visit in that calendar year.

• There is an overall out-of-pocket limit per person and that might change annual as directed by the Internal Revenue Service (IRS). Please check with the Fund Office or download Fund’s Summary of Benefits and Coverage document for the Plan(s) in question. Once this limit has been reached the Plan will reimburse all covered in-network services for the balance of that calendar year at 100%. This limit takes into account all monies paid by a participant or a family member out of his/her pocket for the following:

  • The annual deductible (for C4 it is $3,000 per individual/$7,500 per family – this is the amount that must be paid before the Plan makes any reimbursement).

  • All co-payments (the flat dollar amount paid at the time of a service; e.g. $250 for an emergency room visit under Plan C4).

  • All co-insurance payments – the 50% cost sharing for in-network services provided by physicians, laboratories, diagnostic tests, surgical services, prescription drugs, etc.

• Are there any items not subject to the out-of-pocket limit?

  • Yes, a participant or a covered family member will be wholly responsible for full payment of any out-of-network services or provider charges and for any item not covered under the Plan, and these payments will not count toward the out-of-pocket limit.

The out-of-pocket limit that previously existed only took into account co-insurance percentages for hospital, medical, and surgical services. Co-payments and deductibles for medical services and prescription drug co-payments and/or co-insurance percentage payments were not included in the limit. Under the ACA, all essential benefits must be wrapped into an overall out-of-pocket limit (dental and vision benefits are not included as they are not essential benefits). The existing limits were increased slightly to account for the added prescription utilization and the inclusion of co-payments and deductibles. Once you have met the out-of-pocket limit, whether because you incurred expenses for different types of services, or just one (such as a hospitalization with or without surgical services or high prescription usage), the Plan will pay all remaining covered services at 100% for the remainder of the year in which you met the limit.

Because Plan C runs on a quarterly basis, the Trustees decided that forfeitures should also be run quarterly instead of annually to better comport with the Plan. We will look at the prior eight (8) coverage quarters, or 24 coverage months, (before statements for the prospective coverage quarter are generated) to determine if there was ‘activity’ in the CAPP account. The definition of ‘activity’ is not changing; ‘activity’ means coverage in an active option (A, C1, C2, C3, or C4), submission of a covered claim for medical reimbursement, or an employer contribution to the Plan. If there was ‘activity’ in any of the 8 prior coverage quarters then the account balance remains. The absence of any one of the three types of activity will cause a forfeiture of the CAPP account balance to general Plan assets.

Under Medicare’s secondary payor rules a person who is enrolled in Medicare but continues to work (is no longer considered retired and is considered active, as defined by Medicare) and who has group coverage available to them may not use Medicare as their primary coverage and use the group coverage (such as Plan C-MRP) as secondary to Medicare. (As explained below, you can waive Plan C coverage and stay on Medicare). The Fund’s definition of ‘active’ for such participants is if they work and have employer contributions received in a contribution test quarter that equal or exceed the Plan’s lowest cost coverage. Since C4 will be the lowest cost coverage as of January 1, 2015, the cost of C4 individual coverage will be used to determine who is active. A participant who meets the active test must enroll in active coverage and freeze any retiree medical reimbursement monies they may have, or the Fund will enroll them in C4 coverage absent an active election for any other coverage option. They will be given the right to waive their active Plan C account so they do not have to give up Medicare as their primary coverage for the prospective quarter but their retiree medical reimbursement account will continue to be frozen for the prospective coverage quarter since they met the active test.

If you fail to timely submit the required proof of other employer/union sponsored group health coverage along with the completed and signed certification that such other coverage provides “minimum value” (as defined by the ACA), you will be defaulted into Plan C-2, C-3 or C-4 single coverage if your CAPP account balance is sufficient to cover the entire cost of such coverage for one quarter. If you were enrolled in the MRP as a stand-alone option in the previous year and wish to waive your CAPP balance entirely so that you may be eligible for a government subsidy if you buy coverage on the Health Insurance Marketplace, you may request a waiver form from the Fund Office or download it on our website at www.iatsenbf.org.

If your CAPP account balance is not sufficient to cover the cost of at least one month of C-4 single coverage, your coverage from the Fund will lapse. Once your coverage lapses, you will not be offered Plan C coverage again until you have enough in your CAPP account to cover the cost of at least one month of C-4 single coverage (and you may at that time opt for that coverage or co-pay for more expensive coverage). You will not be automatically defaulted into Plan C coverage until your account is sufficient to cover at least the cost of one quarter of C-2 single coverage (and the current $150 administrative fee).

You can check your balance by logging into the Funds website at www.iatsenbf.org. Click the“ current coverage” link under the Health & Welfare panel on your main Dashboard page. Your“ ending balance” is the amount available for reimbursement of qualified, previously unreimbursed, medical expenses or post-tax health insurance premiums. You can also obtain your balance by calling the Participant Services Center at 1-800-456-3863 or by referring to your Plan C quarterly statement. Please note, your on-line balance will be different from your statement if claims were processed after the statement was generated.

Claim forms are available on the Fund’s website at www.iatsenbf.org by clicking on the “Applications/Forms/Documents” link under Participant Quick Links on the main landing page. Or, in the “search” box, enter “Medical Reimbursement claim form” and hit submit. You can also obtain a form by requesting one through Participant Services Center by calling 800-456-3863 or via email at psc@iatsenbf.org. Please check back often to obtain the most current claim form.

Make sure you have signed your claim form. Attached all itemized, current bills and your other coverage EOB (Explanation of Benefits) from your insurance company and mail to:

   I.A.T.S.E. National Benefit Funds

   417 Fifth Avenue, 3rd Floor

   New York, NY 10016

   Attn: MRP Claims

Or, you can also upload your claims via the Fund’s website at www.iatsenbf.org. Be sure to include all documents listed above and sign the electronic consent certificate on the Fund’s website.

No. All dependents must be enrolled in an employer or union sponsored group health coverage plan for each to be eligible to submit claims for reimbursement.

No. A claim must be incurred after the effective date of your enrollment in the R-MRP Plan and during a period that you are still enrolled in the R-MRP Plan for reimbursement from your R-MRP Plan.

You may submit the claim to the Fund Office in one of four ways:

•By logging on to your website account at www.iatsenbf.org. Scan your document(s) and upload (no MRP claim form is required when uploading via the website)

•By email as a PDF attachment to psc@iatsenbf.org

•By Fax to: 646-783-7650

•By Mail to:

   I.A.T.S.E. National Benefit Funds, MRP Claims Department

   417 Fifth Avenue, 3rd Floor

   New York, NY 10016

You can check the status of your MRP claim by going to our website and logging into your account.

You need to complete a Medical Reimbursement claim form (signed and dated) for each patient (including any dependent enrolled in an employer or union sponsored group health coverage plan that meets the ACA minimum value standard) along with supporting documentation for each expense such as an itemized bill from the provider and the Explanation of Benefits (EOB) from your insurance carrier.

 If you are submitting through the website at www.iatsenbf.org:

 •You do not need to complete a claim form however all of the above will be required and you will also be required to checkoff a box certifying the following:

   oThe submitted expenses have not been previously reimbursed and are not reimbursable under any other health plan coverage

   oThe submitted expenses are qualified medical expenses as defined by the Internal Revenue Service under IRS Publication 502 (as described in our MRP Guidebook )

   oThe submitted expenses are for a dependent enrolled in an employer or union sponsored group health coverage plan that provides minimum value (effective January 1, 2017)

   oIf the reimbursements requested are for health insurance premiums, that those premiums were paid on a post-tax basis (eg. Not through a pre-tax flex spending account or pre-tax deductions made by you or your spouse’s employer through payroll deductions).

   oThat all the information you have provided in support of the claim you are submitting is complete, true and correct and all charges for which you are requesting reimbursement were paid by you or your dependent, where applicable.

Please note: You must be enrolled in the Plan C-MRP both when the expense is incurred and when you submit a claim for reimbursement. To be eligible for reimbursement under the Plan C-MRP, your expense must be a qualified post-tax medical coverage premium or appear on the list of qualified unreimbursed medical expenses. Please refer to the Medical Reimbursement Guidebook for Plan C and Plan R-MRP SPD for a list of qualified expenses.

1.Log into the website at www.iatsenbf.org

2. Accept the terms and conditions

3.You will be brought to your dashboard. Under the Health & Welfare column is the new “MRP History/New Claim” button.

  Click this button to:

   oUpload a new claim

   oUpload additional information for a previously submitted claim

   oCheck the status of a claim

   oView existing claims

   oSee what is covered/reimbursable

   oDownload a claim form

4.When you click on “Submit New Claim” a certification and conditions of reimbursement box appears. You MUST check this box to go to the next step. Check the box and click on proceed.

5.The “New Claim Submission” box will come up. You must click on the applicable patient you are uploading claims for. Click on the applicable patient and click on the “Step 2” button.

6.You will be asked to verify your address and direct deposit information (if applicable). You can modify both in this screen. If you are currently receiving direct deposit you have the option of switching to paper check and vice versa.

7.After reviewing your address and direct deposit information, click on the “Step 3” button which brings you to the upload claims screen.

8.Click on “browse”, find the document in your computer system and click on “upload”. The files that are uploaded will show below the “Claim Documents”. Once you have finished uploading claims, click on “Submit Claim”. You will receive a web reference # for your submission.

9.You have the option of clicking on “Submit Another Claim” or “Go to MRP Claims Homepage”.

10.If you click on “Go to MRP Home Page” it will bring you back to the initial “My Claims & Reimbursements Summary” screen.

You will receive a check in the mail along with an EOB (Explanation of Benefits). Or, if you opted for direct deposit, only the EOB will be mailed to you.

If you would like to have your payment directly deposited to your bank account, you must fill out a direct deposit form or go to our website, log into your account and click and the “change direct deposit information” tab to enter your banking information. Note, once an MRP direct deposit form/website request is received, a pre-notification file must be sent to your bank first. Once the pre-notification has been successfully sent and your bank confirms that the banking information submitted is correct, the next reimbursement you receive will be sent via direct deposit. The verification of the account can take up to two weeks and can take longer if the account information is not entered correctly the first time. Please be sure to update your direct deposit information immediately if your banking information changes. Direct deposit information cannot be updated over the phone. Your payment will be directly deposited to your account once the claim has been processed and a separate explanation of benefits will be sent via mail. The explanation of benefits is also viewable online via the website at www.iatsenbf.org.

Before you fill out the direct deposit form, be sure you know your bank’s routing number and your account number. If you have a checking account, this information can be found on the bottom of a check (see image).

You may refer to the Plan C-MRP Guidebook and Plan R-MRP SPD for a detailed list of qualifying expenses that are eligible for reimbursement in accordance with the IRS definition and Publication 502. Some of the most common eligible expenses are:

   •Medical co-payments, prescription co-payments, co-insurance amounts and deductibles

   •Insurance premiums (post-tax and employer/union sponsored health plans only)

   •Dental expenses

   •Vision expenses

All claims are processed within 30 days of the receipt date of the MRP claim.

Yes. An administrative fee is charged for processing all MRP claims. The chart below details the current fees:

Amount of Claim Eligible for Reimbursement	Administrative Charge as % of Claim
$1-$249	5.0%
$250-$499	4.5%
$500-$999	3.5%
$1000-$1,999	2.5%
$2000 or more	2.0%

No. you only need to submit an explanation of benefits document from your other group coverage and itemized statement from your provider along with a completed and signed MRP Claim form.

No. payments can only be issued to the participant.

No. you would have to resubmit the claim again to receive the unreimbursed balance. You would need to complete a new MRP Claim form and submit the original explanation of benefits you received from the Fund Office.

Reminder: Claims must be submitted no more than 12 months from the date of service

If there is no activity (contributions received, claim(s) paid, or premium charges) within the past 8 quarters, then all contribution are forfeited.

Yes. you must be enrolled in the stand-alone MRP option at the time of the claim submission. If you are covered under Plan C1, C2, C3 or C4 and have excess funds in your CAPP account available for reimbursement, then you can submit for reimbursement of claims incurred as long as they are submitted within the 12 month filing deadline.

If you lose coverage under Plan A, C1, C2, C3, C4 or Triple S, you, or our dependent, will be offered COBRA (self-pay continuation coverage). You have the right to purchase COBRA continuation coverage through the National Health & Welfare Fund until you re-qualify for coverage through employer contributions, qualify for another group health coverage plan or exhaust the time limit for continuation. Instead of electing and paying for COBRA coverage, you may wish to obtain coverage through the Health Insurance Marketplace. With either COBRA or Marketplace coverage, you may avoid a tax penalty for being uninsured. Check with your personal tax advisor to be certain.

The ACA places an annual limit on how much a person is required to pay out-of-pocket for covered services under a health plan. Once a person has met that annual limit, the health plan must cover all covered services at 100% for the rest of the year. While Plans C2 and C3 already contained an out-of-pocket limit, Plans A and C1 did not. And, the limits under Plans C2 and C3 did not include prescription drugs, which now count toward the annual limit starting January 1, 2015. The annual limit includes amounts paid by a participant for all essential benefits: hospital, medical, diagnostic, laboratory, mental health services, covered therapies, prescriptions, etc. (Services not covered by the Plan, such as out of network services under Plans C3 and C4, do not count toward the annual limit). As briefly described above, deductibles, copayments, and co-insurance (percentage) payments are all added together as out-of-pocket monies a participant is spending/cost sharing with the Plan. Once a participant’s spending reaches a certain dollar amount, then all further covered services in that same calendar year are paid at 100%. This means that, after that point, no more out-of-pocket expenses have to be paid by the participant except for non-covered services and out-of-network provider charges that exceed the reasonable and customary dollar amount determined by BlueCross BlueShield (or all out-of-network provider charges if the participant is covered under an in-network-only option).

The out-of-pocket limits under Plans A, C1, C2, and C3 are more generous than required by the ACA, that is, the Plans are reimbursing more than is required by law.