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受托人的意见
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在再保险
原告: 积极的员工
被申请人: 雇主
ROD案例编号: 93-035 - 1996年11月8日
受托人: 托马斯·F. 迈克尔·康纳斯. 霍兰德，唐纳德·E. 皮尔斯,小. 和艾略特A. 西格尔.
受托人审查了有关根据雇主福利计划条款提供福利的争议的事实和情况.
背景事实
申诉人受雇于1993年《皇冠搏彩中心》(“工资协议”)的签署国. 投诉人的代表辩称，被投诉人的福利计划不符合1993年工资协议和雇主福利计划的规定. 具体地说, the representative states that the Respondent has failed to provide a Participating Provider List (PPL) of 医生, 根据1993年《皇冠搏彩中心网站》第20(10)条《皇冠搏彩中心》的规定，医院、药房和其他供应商. The representative states that because the Respondent has failed 来实现 a PPL under the 雇主 Benefit Plan, the Complainants have had to pay higher co-payments and deductibles for non-PPL providers. 该代表还指出，投诉人必须直接支付服务费用，然后再向被投诉人寻求退款. The representative states that some Complainants have received reimbursements and others have not.
The Respondent states that it is not required to establish a PPL under the terms of the 1993 Wage Agreement. 除了, the Respondent states that because of the small size of its organization, 这家公司只雇佣了8名工会员工, it is unable to participate in an existing PPL or to establish its own PPL. Because the Respondent’s benefit plan does not have a PPL, it contends that the non-PPL copayments and other limits apply to the Complainants. 被投诉人没有否认投诉人的指控，即他们被要求支付服务费用，然后要求退款. 然而, 答辩人说，它已改变其索赔处理程序，"以便直接向保健提供者付款, 除非员工指示.”
争端
Is the Respondent’s health plan in compliance with the 1993 Wage Agreement and the 雇主 Benefit Plan?
双方立场
申诉人的立场:申诉人的医疗保险计划不符合1993年《皇冠搏彩中心网站》和雇主福利计划.
Position of the 被申请人: According to the 1993 Wage Agreement, 被申请人不需要建立PPL. Because the Respondent does not have a PPL, the non-PPL co-payments and other limits apply. The Respondent has changed its health care claims processing “so that the health care provider is paid directly, 除非员工另有指示.”
相关的规定
Articles XX (10) and (12) of the National Bituminous Coal Wage Agreement of 1993 provide, 在相关部分:
(10)保健:
加强成本控制计划
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d. 医疗保健参与提供者名单(PPL)
Beginning no sooner than six months after the Effective Date, the 雇主 may implement Participating Provider Lists (PPLs) of 医生, 医院, 药店和其他供应商, 根据以下要求.
* * * * * * * * *
12. PPL地区以外的受益人-居住在PPL服务地区以外的受益人应被允许使用非PPL供应商，而不会产生额外的免赔额和共付额. For purposes of determining the Beneficiary’s deductibles and copayments, utilization of such non-PPL providers shall be considered to be within the PPL.
(12)卫生保健费用控制:
The Union and the 雇主s recognize that rapidly escalating health care costs, including the costs of medically unnecessary services and inappropriate treatment, have a detrimental impact on the health benefit program. The Union and the 雇主s agree that a solution to this mutual problem requires the cooperation of both parties, 在各个层面, to control costs and to work with the health care community to provide quality health care at reasonable costs. 工会和雇主是, 因此, committed to fully support appropriate programs designed to accomplish that objective. This statement of purpose in no way implies a reduction in benefits or additional costs for covered services provided miners, 领取养老金的人和他们的家人.
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第三条. A. (8) of the 雇主 Benefit Plan provides in pertinent part:
(8) 共同支付和免赔额
1月1日生效, 1994, 本计划提供的福利应受下文规定的共付额和免赔额的约束，该等共付额和免赔额应由受益人负责. 计划管理人应执行被认为适当的程序，以实现这些共同付款和免赔额的目的. . . .
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Co-payments for covered 健康的好处 are established below. 有免赔额的服务或用品的共同付款，只有在当年的免赔额全部付清后才适用.
Participating Provider Lists (PPLs) implemented by the 雇主 pursuant to Article IV may include participating 医院, 医生, 药店和其他供应商. 非PPL来源提供的医院和相关福利的计划付款将被限制为如果福利由供应商以PPL(或实际收费)方式提供，计划本应支付金额的90%, 如果更少). . . . In any case where a non-PPL provider is treated as being within the PPL, 根据第IV条C的规定., the Beneficiary will be responsible for the deductible and co-payment that would apply to a PPL service. . . .
医生办公室访问:
PPL: $10.每次诊座00美元 (up to an annual maximum of $200 per family)
Non-PPL: $15.每次诊座00美元
住院费及相关费用:
PPL: 没有费用
Non-PPL: Balance of charges after Plan pays 90% of the PPL rate for covered services from a non-PPL source.
Prescription Drugs (Co-pays do not apply to out-of-pocket maximum):
PPL: $4.每份处方50英镑
Non-PPL: $9.每张处方100美元
邮购:无需自付
第四条A. (1)提供:
第四条管理式医疗，成本控制
A. (1) Effective six months after the Effective Date of the 1993 NBCWA, the employer may adopt Participating Provider Lists (PPLs) of 医生, 医院, 药店和其他供应商, 但须符合C项所载的规定.,低于.
第四条丙. 12. 进一步提供了:
第四条管理式医疗，成本控制
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C. The following requirements apply to a PPL implemented under this Plan:
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12. PPL地区以外的受益人-居住在PPL服务地区以外的受益人应被允许使用非PPL供应商，而不会产生额外的免赔额和共付额. For purposes of determining the Beneficiary’s deductibles and co-payments, utilization of such non-PPL providers shall be considered to be within the PPL.
讨论
The Complainants’ representative contends that the Respondent must implement a PPL program. 1993年工资协议第20(10)条和雇主福利计划第4条规定了管理护理和成本控制目标，旨在以合理的成本向雇主提供高质量的雇员护理. The 1993 Wage Agreement states that “the 雇主 may implement Participating Provider Lists. . . .” Under the terms of the Wage Agreement and the 雇主 Benefit Plan, a PPL is a cost containment program that an employer is allowed, 但不是必需的, 来实现.
第三条. A. 雇主福利计划(雇主 Benefit Plan)第(8)条规定，本计划项下提供的某些福利应受自付额和免赔额的约束. The Beneficiary is responsible for a co-payment of $10 (in PPL) or $15 (non-PPL) for office visits and $4.50美元(PPL)或9美元.00(非ppl)处方药. Under the terms of the Plan, the Beneficiary only pays $200 in co-payments for in-PPL office visits. There is no co-payment for hospitalization and related services from an in-PPL source, 但受益人须在计划为非PPL来源的服务支付90%的PPL费率后负责费用余额.
第三条A. (8)还规定“计划管理人应执行被认为适当的程序，以实现这些共同付款和免赔额的目的。.“PPL内和非PPL的共同支付和免赔额时间表鼓励员工使用PPL成员供应商的服务, which essentially helps to lower the employer’s cost for providing health coverage. According to Article XX (12) of the 1993 Wage Agreement, PPL计划的管理护理和成本控制目标并非旨在“减少矿工提供的承保服务的福利或额外费用”, 领取养老金的人和他们的家人.“如果雇主没有建立PPL, it should implement procedures that allow beneficiaries of its benefit plan to pay the in-PPL co-payments and deductibles. 否则, 没有PPL计划的福利计划的受益人将受到更高的共付额和免赔额的额外费用.
支持这一立场, that the beneficiaries should pay the lower co-payments and deductibles, 第四条丙. 12. 《皇冠搏彩中心网站》规定，如果雇主设立了PPL，且受益人居住在PPL所服务的地区以外, the beneficiary’s co-payments and deductibles for non-PPL providers shall be deemed within the PPL. 这项规定也载于1993年的《皇冠搏彩中心网站》.
申诉人代表说，被申请人的索赔处理程序要求雇员支付医疗服务费用，然后要求报销. 根据工资协议条款，通常的索赔申请程序是受益人应授权提供商向保险公司开具所提供服务的账单，并仅支付第III A条规定的共同支付额. (8)直至指定为止
已达到年最大金额. 被投诉人代表所描述的索赔处理程序和支付方式与1993年工资协议和雇主福利计划所设想的索赔程序不一致.
受托人的意见
The Respondent is allowed, but is not required, 来实现 a PPL program. 在没有PPL时, the Complainants’ co-payments and deductibles when utilizing non-PPL providers shall be considered to be within a PPL. 被投诉人代表所描述的被投诉人处理索赔的程序和付款方式与雇主福利计划和1993年工资协议条款所设想的索赔程序不一致.