Types of Medical Plans

A medical plan is a type of benefit plan that pays all or a portion of eligible expenses if you or a covered family member is ill or injured. Medical plans typically cover a range of services related to health care, such as preventive care, doctor office visits, diagnostic lab tests and x-rays, hospital stays, surgery and prescription drug benefits. Most medical plans cover similar services and supplies. However, different plans pay different levels of benefits when you have a covered expense, and the way in which you access care may be different, depending on the type of plan.

Below are brief descriptions of the most common types of medical plans and how they work. Please note that the information found here is general information. For specific information regarding Benefit Trust Fund plans, contact the Fund Office or read the Summary Plan Descriptions of each plan.

Health Maintenance Organization (HMO)

Participants in an HMO must choose a Primary Care Physician (PCP) from among the doctors that participate in the HMO’s network. The PCP coordinates care by referring participants to other doctors or specialists who participate in the same network. There is usually no coverage for services received from non-network providers, except in case of emergency. Generally, medical providers in an HMO network are paid a fixed, negotiated amount for the services they provide.

Exclusive Provider Organization (EPO)

Similar to an HMO, an EPO pays benefits when care is received from EPO network providers. There is usually no coverage for services received from non-network providers. Unlike HMOs, however, EPOs do not require participants to choose a PCP, nor must participants see a PCP or receive a PCP referral in order for benefits to be paid under the plan.

Preferred Provider Organization (PPO)

Participants enrolled in a PPO medical plan receive benefits regardless of whether they see a PPO network doctor or a non-network doctor. However, participants pay less out of pocket when receiving network care because network providers have agreed to charge discounted fees. Participants in a PPO plan are not required to choose a PCP, nor must they see a PCP or receive a PCP referral in order for network benefits to be paid under the plan.

The Benefit Trust Fund medical plans are PPO plans under the CIGNA Open Access Plus PPO network. Participants in the CIGNA Open Access PPO plan receive benefits regardless of whether they see an Open Access network doctor or a non-network doctor. However, participants pay even less out-of-pocket expenses when receiving network care because Open Access network providers have agreed to even greater discounts than their PPO network counterparts. Participants in the Open Access PPO plan are not required to choose a PCP, nor must participants see a PCP or receive a PCP referral in order for network benefits to be paid under the plan.

Point-of-Service (POS)

Participants enrolled in a POS medical plan receive benefits regardless of whether they see a POS network doctor or a non-network doctor. However, participants pay less out of pocket when receiving network care because network providers have agreed to charge discounted fees. Participants in a POS plan must choose a PCP and must see their PCP or receive a PCP referral in order for network benefits to be paid under the plan.

Open Access Point-of-Service (OAP POS)

Open Access POS medical plans are similar to POS plans, except participants are not required to choose a PCP or to see a PCP or receive a PCP referral in order for network benefits to be paid under the plan.

High Deductible Health Plan (HDHP)

A high deductible health plan is typically a PPO medical plan with an annual deductible that is much higher than the deductible in more traditional health plans.

High deductible plans are often accompanied by a medical savings account, which include health reimbursement accounts (HRA) or health savings accounts (HSA). HRAs and HSAs are special kinds of tax-advantaged savings accounts used to help pay for eligible medical expenses (as determined by the IRS) and for expenses paid toward meeting the annual deductible. Funds deposited in an HRA or HSA by an employee and/or the employer, up to IRS limits, are not subject to federal income tax. Similarly, funds are not taxed when used to pay for eligible medical expenses.

  • Health Reimbursement Account (HRA): This is an individual account established for the plan participant and funded only by the Plan. Typically, funds remaining in your HRA at year-end roll over to the next year's HRA allocation to cover future medical costs. HRAs are not portable, meaning if a participant leaves an employer, he or she must forfeit the account to the employer.
  • Health Savings Account (HSA): Like an HRA, HSAs are individual accounts established for a participant in an HDHP plan. Employees and employers may contribute to the HSA. To open an HSA, a participant must be enrolled in a HDHP. HSA funds roll over and accumulate year to year if not spent in the current year. Unlike HRAs, HSAs are portable, meaning that if an employee leaves an employer, he or she can keep the money in the account and use it to pay for eligible health care expenses at a later point. With some HSAs, employers may offer participants the opportunity to invest HSA funds, typically after meeting a minimum account balance.
  • IAMNPF Image

The Benefit Trust Fund medical plans are PPO plans under the CIGNA Open Access Plus PPO network.

Frequently Asked Question (FAQ)

How many different plans does the Fund offer?

The Fund offers multiple Medical, Dental, and Vision plans. Short-Term Disability and Life and Accidental Death & Dismemberment benefits are also available.

How do I notify the Fund of my address change?

If you move, please notify the Fund of your new address. To change your address,
fill out a new Enrollment Form and mail or fax it to the Fund using the mailing address or fax number found on the form. Always complete a new Enrollment Form when you have a change in personal information.

How often are rates subject to change?

All Plans are reviewed annually; notification of rate changes is provided 30-60 days in advance of the renewal effective date.

How many different plans does the Fund offer?

The Fund offers multiple Medical, Dental, and Vision plans. Short-Term Disability and Life and Accidental Death & Dismemberment benefits are also available.

How do I notify the Fund of my address change?

If you move, please notify the Fund of your new address. To change your address,
fill out a new Enrollment Form and mail or fax it to the Fund using the mailing address or fax number found on the form. Always complete a new Enrollment Form when you have a change in personal information.

Do Medical Plans include Prescription Drug Coverage?

Yes. Our Plans include excellent prescription drug benefits.

What is a PPO?

A Preferred Provider Organization is a type of medical plan that covers the cost of eligible medical care and services received from network and non-network providers. Network providers (primary care doctors, specialists, hospitals, and other medical facilities) agree to a discounted fee schedule for services provided. When a participant or covered family member sees a network provider for care, the participant pays less out of pocket because of the discounted fees. The Fund contracts with CIGNA Healthcare for the use of their nationwide network of participating providers. There are currently more than 750,000 participating providers in the CIGNA "Open Access Plus" Network—the network used by the Fund’s medical plans.

Are participants required to receive services only from a PPO provider?

No. Participants have the choice of selecting a non-PPO physician. However, receiving services from a physician who participates in the CIGNA network may result in significant savings for participants.

Must participants have a referral from their primary care physician in order to see a specialist?

No. Referrals are not required.

Who processes health care plan claims?

Medical claims are processed by CIGNA Healthcare. Dental claims are processed by Delta Dental Insurance Company, and Vision claims are processed by Fund Office staff.

Do the Fund plans have a waiting period for "pre-existing conditions" under the medical plans?

No. The waiting periods for pre-existing conditions were waived for all plans by the Board of Trustees.

What are the age limits for dependent children?

Children can be covered dependents until they reach age 26 providing they continue to meet provisions for dependent coverage.

Does the Fund offer COBRA coverage for health care?

Yes. The Fund administers COBRA for its Contributing Employers. Upon notification from the Employer that a participant is losing coverage due to a "qualifying event," the Fund will send notification to the participant advising him or her of COBRA rights to continue health care coverage by making payments to the Fund Office.

Does the Fund offer Retiree Health Care Plans?

Yes. Employers that have negotiated a Benefit Trust Plan for their Active employees may also establish a Retiree plan.

How Do I Find a Contributing Employer?

To find a Contributing Employer click on this link to view a map and listings by territory.

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