Northwest Carpenters Health and Security Plan

Medical Coinsurance 

After you satisfy your $200 annual deductible, you share a percentage of the remaining covered expenses with the plan. There are three coinsurance payment levels depending on (1) the type of service or supply received; (2) if the provider is network or non-network; and (3) the type of health care provider used:

• 90% – 10% If you use a network provider, most covered medical expenses are paid at 90 percent by the plan and at 10 percent by the patient. When the patient’s coinsurance reaches $2,300 in a calendar year, benefits that would otherwise be paid at 90 percent are paid at 100 percent for the remainder of that calendar year.
• 80% – 20% If you use a non-network provider, most covered medical expenses are paid at 80 percent of the maximum allowable fee by the plan and at 20 percent of the maximum allowable fee by the patient. These services always require 20 percent coinsurance and these coinsurance payments do not apply toward the $2,300 or $4,600 annual coinsurance maximums. Even though there are network chiropractors, covered chiropractic expenses are also paid at 80 percent by the plan and at 20 percent by the patient. The following exceptions apply:
  • If you receive emergency services from an emergency department at a non-network hospital or freestanding emergency department for an emergency medical condition, including examination and treatment to stabilize the patient, regardless of the department in which the services are furnished, the plan will pay covered expenses at 90 percent/100 percent of the maximum allowable fee and coinsurance expenses will apply toward the annual coinsurance and out-of-pocket maximums.
  • If you receive services that are not available from a network provider or hospital, the plan will pay covered expenses at 90 percent/100 percent of the maximum allowable fee and coinsurance expenses will apply toward the annual coinsurance and out-of-pocket maximums. You must submit proof that the services were not available from a network provider or hospital.
  • If you receive services from a non-network provider at a network facility, the plan will pay covered expenses at 90 percent/100 percent of the maximum allowable fee and coinsurance expenses will apply toward the annual coinsurance and out-of-pocket maximums.
  • 50% – 50% Covered orthognathic surgery and TMJ/MPDS expenses are paid at 50 percent by the plan and at 50 percent by the patient. These services always require 50 percent coinsurance and TMJ/MPDS coinsurance payments do not apply toward the $2,300 or $4,600 annual coinsurance maximums.

Medicare-eligible retirees expenses are processed at the network level.

Last Updated: 04/25/2023