September 10, 2020
Control Number: 81-63
Subject: Copayments for HMO Enrollees
References: Amended 1950 & 1974 Benefit Plans & Trusts,
Article III, Sections A (8) and A (10) (a)
Question:
Do the copayment provisions of the Plan apply to Beneficiaries enrolled in Health Maintenance Organizations?
Answer:
No. The scope of benefits under the Plan, including the copayment provisions, does not apply to a Beneficiary enrolled in an HMO. The Beneficiary makes a free election between the HMO benefit structure and that provided by the Plan. If the Beneficiary elects the HMO, he/she assumes responsibility for paying for any copayments imposed by the elected HMO, as well as for any charges in excess of the cost of health benefits provided under this Plan.