Medical Plan
Your medical plan pays benefits for both in-network and out-of-network care and includes a Health Reimbursement Account — or HRA — funded by Tidelands Health. It also includes coverage for prescription drugs.
About the Plan
- You will save the most money when you choose in‐network doctors and facilities through Tidelands Health.
- Benefits will also be paid for in-network providers that you access through Blue Preferred PPO, but you will pay more out of your pocket.
- Out-of-network benefits are paid for doctors, facilities and pharmacies that are not part of either the Tidelands Health or Blue Preferred PPO networks. However, you will pay the most out of your pocket when you go out-of-network.
About the Health Reimbursement Account
The medical plan includes an HRA funded by Tidelands Health. Each year, you have the opportunity to earn an HRA contribution by completing YouCare activities. The amount of your HRA contribution depends upon completing required activities and the Coverage Tier you select each year during Open Enrollment. You can use your HRA contribution dollars to help pay for qualified medical, dental, and vision out-of-pocket expenses. Learn more about the HRA and how much Tidelands Health contributes.
Quick Cost Comparison
Below is a quick summary of your out-of-pocket costs when you use in-network and out-of-network providers. For more information, view a detailed comparison.
| In-Network | Out-of-Network | ||
|---|---|---|---|
| Tidelands Health | Blue Preferred PPO | ||
| Office Visits Primary Care, including Telehealth/ Telehealth Specialist |
$25 copay* $50 copay* |
$50 copay* $100 copay* |
50% after deductible (no Telehealth) |
| Deductible | |||
| Individual | $1,500 | $3,000 | $4,500 |
| Family | $3,000 | $6,000 | $9,000 |
| Out-of-Pocket Maximum | |||
| Individual | $3,000 | $6,000 | $9,000 |
| Family | $6,000 | $12,000 | $18,000 |
| Coinsurance | 15% | 25% | 50% |
| Emergency Room | 15% after deductible | 15% after deductible | 15% after deductible |
* Deductible waived
Make the Most of Your Benefits
Where you go for care matters, both to your health and how much you’ll pay. It’s smart to be aware of factors that impact your costs:
Save When You Stay In-Network
Need lab work? Eligible Outpatient Labs are covered at 100% when performed at a Tidelands Health Hospital, as well as labs submitted through our hospitals by Tidelands Health Physician Practices. Non-preventive labs and tests processed through LabCorp or other outside labs are subject to the plan deductible.
Use Quantum Health Care Coordinators
Care Coordinators are your personal healthcare advocates with a team of dedicated nurses, health benefit experts and claims specialists. Contact them for guidance to help ensure you have the best health experience at an affordable cost. They can:
- Issue/replace ID cards
- Answer claims, billing and benefits questions
- Help manage chronic conditions
- Find in-network providers
- Help reduce unnecessary out-of-pocket costs
Log on to tidelandshealthplan.com or call 877-498-6693.
Be Knowledgeable about Balance Billing
The amount the plan pays for covered services provided by non‐network providers is based on a maximum allowable amount for the specific service rendered. Although the plan features an out‐of‐pocket maximum for out‐of‐network services, please note the maximum allowed amount for an eligible procedure may not be equal to the amount charged by your out‐of‐network provider. They may bill you for the difference between the amount charged and the maximum allowed amount. This is called balance billing, and the amount billed to you can be substantial.
The plan’s out‐of‐pocket maximum will not include amounts more than the allowable charge and other non‐covered expenses as defined by your plan. The maximum reimbursable amount for non‐network providers can be based on a number of schedules, such as a percentage of reasonable and customary or a percentage of Medicare.
The plan document or carrier’s master policy is the controlling document, and this summary does not include all of the terms, coverage, exclusions, limitations, and conditions of the actual plan language. Call your Quantum Health Care Coordinator at 877-498-6693 if you have questions about the amount being billed by your provider.
Review Your Medical Plan Explanation of Benefits (EOB)
Your claims are administered by Planned Administrators, Inc.— PAI. Visit them at paisc.com for more information or to find your claim’s Explanation of Benefits (EOBs). If you’re newly enrolled, select “Member Portal” and create your profile using the name shown on your ID Card. PAI also offers several value‐added discounts programs.
Sign Up for MASA Medical Transportation Services
All full- time and part-time employees are eligible to sign up for a membership with MASA Medical Transportation Services — MTS, even if you are not enrolled in the Tidelands Health medical plan. Choose from two plans:
- Emergent Plus provides emergency air and ground transportation services anywhere in the United States and Canada, regardless of whether the provider is in or out of a medical plan’s provider network.
- Platinum provides all of the above, plus emergency transportation services worldwide.
Enroll at any time through Workday. Learn more about the Emergent Plus and Platinum memberships.
| MASA MTS Monthly Premiums | |
|---|---|
| Emergent Plus Membership | $14.00 |
| Platinum Membership | $39.00 |