Plan Definitions
For more information, please reference the Summary Plan Description.
Health Reimbursement Account (HRA). The LSU System funds your HRA at the beginning of each Plan Year based on the Plan Option and level of coverage elected. The HRA is the first portion of your Deductible and pays for 100% of Covered Expenses from any Provider as of the date of service until the HRA is exhausted. If you exhaust your HRA, you are responsible for meeting 100% of your Remaining Deductible and paying your share of any additional healthcare costs you incur during the Plan Year. Remember, claims for First Choice Providers and generic drugs will be paid at 100% by LSU First after your current Plan Year HRA is exhausted.
HRA Rollover. Any balance in your HRA at the end of the Plan Year will be rolled over to the next Plan Year up to a maximum. HRA Rollover will be applied to your Remaining Deductible and Co-Insurance, if available. Rollover funds will not be used to pay for generic drugs or First Choice Providers, but will be used for other Covered Expenses, such as In-Network and Out-of-Network services.
The Deductible. The Deductible includes your Health Reimbursement Account (HRA) and your Remaining Deductible. The amount of your Deductible is based on your level of coverage and the effective date of your coverage.
Remaining Deductable. The Remaining Deductible amount is your Deductible less your HRA. After you have exhausted your HRA, you are responsible for paying 100% of Covered Expenses (including medical and pharmacy) up to the amount of your Remaining Deductible. HRA Rollover will be applied to your Remaining Deductible and Co-Insurance, if available.
Co-Insurance. After you have satisfied your Deductible, you enter the Co-Insurance component of the Plan. You pay a percentage of Covered Expenses until you have reached the Out-of-Pocket Maximum for your Level of Coverage once your Deductible has been met.
Out-of-Pocket Maximum. To protect you, LSU First has established the maximum amount you will pay in the Co-Insurance component. This is referred to as the Out-of-Pocket Maximum. Your percentage of Co-Insurance for Covered Expenses accumulates to the Out-of-Pocket Maximum. The Out-of-Pocket Maximum varies based on your Level of Coverage and whether or not services are rendered by an In-Network or Out-of-Network Provider.
Health Care Provider Networks. In a “network,” health care providers have contracted to accept fixed amounts for services or supplies. “Out-of-network” providers have not contracted to accept fixed amounts for services or supplies. There are currently three provider networks available for LSU First members: the First Choice Provider network, the CIGNA Open Access Plus network, and the Verity HealthNet network. You may also use out-of-network providers.
First Choice Provider. A Healthcare Provider that has met certain established standards and who has agreed to accept certain fixed fee payments from the Plan for Covered Expenses. By utilizing a First Choice Provider, you incur no Remaining Deductible or Co-insurance responsibility.
In-Network. When you access a Provider through either CIGNA (Open Access Plus) or Verity HealthNet, you’ll save money. In-Network Providers have agreed to a Contracted Reimbursement Rate. Therefore, you can make your HRA go further by using an In-Network Provider. In addition, the Co-Insurance component will pay a greater percentage of Covered Expenses billed by an In-Network Provider.
Out-of-Network. An Out-of-Network Provider is a health care provider that has not entered into a contract or agreement directly with a network of providers accessed by LSU First. Providers cannot be required to become Contracted Health Care Providers.
Contracted Reimbursement Rate. The aggregate maximum amount that a contracted health care provider has agreed to accept from all sources for provision of covered health care services under the health insurance coverage applicable to the enrollee or insured.
Covered Expenses. Covered Expenses are the amount of payment for Covered Services. For In-Network Providers, Covered Expenses are limited to the Contract Reimbursement Rate set forth in the applicable contract with the Contracted Health Care Provider. Covered Expenses for Out-of-Network Providers are limited to the Maximum Reimbursable Charge (MRC) for the items or services furnished, as determined by the Plan Administrator.
Prescription Drug Benefit. LSU First provides medical and pharmacy coverage under one plan. Express-Scripts Inc. currently manages your prescription drug coverage. There is no formulary for prescription drugs. LSU First will cover all FDA approved medications.
Compounded Medications. Compounded medications are drugs which must be formulated by the pharmacist. Unfortunately, most pharmacies providing these types of medications do not accept insurance, so you will have to pay at the time of service and submit a reimbursement form to Express Scripts. Some compounded medications are not FDA approved. For your safety, LSU First only covers medications that are FDA approved.
Pre-existing Condition. A Pre-existing Condition occurs when you or your eligible Dependent receives medical care or has been diagnosed or treated for any Sickness or Injury within six months before coverage under this Plan begins. A Pre-existing Condition does not include Pregnancy. Genetic information is not an indicator of a Pre-existing Condition, if there is not a diagnosis of a condition related to the genetic information. If you have Creditable Coverage, you or your Dependent will be eligible to receive Plan Benefits for a Pre-existing Condition. Creditable Coverage is defined above.
Maximum Reimbursable Charge (MRC)/Usual and Customary (U&C). The Maximum Reimbursable Charge is determined solely by the Plan Administrator for Out-of-Network services and is developed in the following evaluation and validation in accordance with one or more of the following methodologies:
- As indicated in the most recent edition of the Current Procedural Terminology (CPT), a publication of the American Medical Association, and or the Centers for Medicare and Medicaid Services (CMS).
- As reported by generally recognized professionals or publications
- As used for Medicare.
- As determined by outside medical consultants pursuant to other appropriate source or determination that we accept.
In addition to all of the above, to assist in the determination of the Maximum Reimbursable Charge for a service or supply that is unusual, not provided in the Geographic Area, or provided by a small number of Providers, the Plan Administrator will consider the following:
- The complexity of the service or supply.
- The degree of skill needed.
- The Provider’s specialty.
- The range of services or supplies provided by a facility
- Plan fees for similar services in other areas