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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.
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the 雇主 Benefit Plan.
背景事实
The Complainants are employed in classified positions with the Respondent who is signatory to the National Bituminous Coal Wage Agreement (“Wage Agreement”) of 1993. A representative for the Complainants contends that the Respondent’s benefit plan does not comply with the provisions of the 1993 Wage Agreement and the 雇主 Benefit Plan. 具体地说, 该代表声明答辩人没有提供医生的参与医疗提供者名单, 医院 and 药店和其他供应商 as required under the 加强成本控制计划 provisions of Article XX (10) of the 1993 Wage Agreement. 该代表指出，因为答辩人未能根据雇主福利计划实施PPL, 投诉人必须为非ppl提供者支付更高的共付额和免赔额. The representative also states that the Complainants have had to pay for services directly and then seek reimbursement from the Respondent. 该代表说，一些申诉人已收到报销，而另一些则没有.
答辩人指出，根据1993年工资协议的条款，它不需要建立一份PPL. 除了, 答辩人说，因为其组织规模小, 这家公司只雇佣了8名工会员工, 它不能参加现有的PPL或建立自己的PPL. 因为被告的福利计划没有PPL, 它认为，非保赔共付和其他限制适用于投诉人. The Respondent does not deny the Complainants’ allegations that they were required to pay for services and then seek reimbursement. 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
被申请人的健康计划是否符合1993年工资协议和雇主福利计划?
双方立场
Position of the Complainants: The Respondent’s health coverage plan does not comply with the 1993 Wage Agreement and the 雇主 Benefit Plan.
被访者职位:根据1993年的工资协议, 被申请人不需要建立PPL. 由于被申请人没有PPL，因此适用非PPL共同付款和其他限制. 被申请人已改变其医疗保健索赔处理“，以便医疗保健提供者直接支付, 除非员工另有指示.”
相关的规定
1993年《皇冠搏彩中心》第20条第10款和第12款规定, 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)
在生效日期后不早于六个月开始, 雇主可以实施医生参与提供者名单(ppl), 医院, 药店和其他供应商, 根据以下要求.
* * * * * * * * *
12. Beneficiaries Outside PPL Area – A Beneficiary who lives outside an area served by a PPL shall be permitted to utilize non-PPL providers without incurring additional deductibles and copayments. 用于确定受益人的免赔额和共付额, 对此类非PPL供应商的使用应被视为在PPL范围内.
(12)卫生保健费用控制:
工会和雇主认识到，保健费用迅速上升, 包括医疗上不必要的服务和不适当治疗的费用, 对健康福利计划有不利影响吗. 工会和雇主一致认为，解决这一共同问题需要双方的合作, 在各个层面, 控制成本，并与卫生保健社区合作，以合理的成本提供优质的卫生保健服务. 工会和雇主是, 因此, 承诺全力支持为实现这一目标而设计的适当项目. 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)《皇冠搏彩中心》相关部分规定:
(8) 共同支付和免赔额
1月1日生效, 1994, the benefits provided in this Plan shall be subject to the co-payments and deductibles set forth below and such co-payments and deductibles shall be the responsibility of the Beneficiary. The Plan Administrator shall implement such procedures as deemed appropriate to achieve the intent of these co-payments and deductibles. . . .
* * * * * * * * *
承保健康福利的共同支付额规定如下. Co-payments for services or supplies subject to a deductible only apply after the deductible has been met in full for the year.
雇主根据第4条实施的参与供应商名单(ppl)可包括参与医院, 医生, 药店和其他供应商. The Plan payment for 医院 and related benefits provided from a non-PPL source will be limited to 90% of the amount that would have been paid by the Plan if the benefit had been provided by a provider on a PPL (or actual charges, 如果更少). . . . 在任何情况下，非PPL提供商被视为在PPL内, 根据第IV条C的规定., 受益人将负责适用于PPL服务的免赔额和共付额. . . .
医生办公室访问:
PPL: $10.每户家庭每年最多可获200元
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: 计划为非PPL来源的承保服务支付90% PPL费率后的费用余额.
处方药(自付额不包括自付额):
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)自1993年《皇冠搏彩中心网站》生效之日起6个月生效, 雇主可采用医生的参与提供者名单, 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
* * * * * * * * *
C. 以下要求适用于根据本计划实施的PPL:
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12. Beneficiaries Outside PPL Area — A Beneficiary who lives outside an area served by the PPL shall be permitted to utilize non-PPL providers without incurring additional deductibles and co-payments. 用于确定受益人的免赔额和共同支付额, 对此类非PPL供应商的使用应被视为在PPL范围内.
讨论
投诉人的代表主张被投诉人必须实施PPL计划. Article XX (10) of the 1993 Wage Agreement and Article IV of the 雇主 Benefit Plan set forth managed care and cost containment objectives designed to provide quality care for employees at reasonable cost to the employer. 1993年工资协议规定“雇主可以实施参与供应商名单”. . . .“根据工资协议和雇主福利计划的条款, PPL是雇主允许的成本控制计划, 但不是必需的, 来实现.
第三条. A. (8) of the 雇主 Benefit Plan provides that certain benefits provided under the Plan shall be subject to co-payments and deductibles. 受益人负责共同支付10美元(PPL)或15美元(非PPL)的办公室访问费用和4美元.50美元(PPL)或9美元.00(非ppl)处方药. 根据本计划的条款，受益人只需支付200美元的ppl内办公室访问共付费用. 住院和相关服务不需要从ppp内的来源共同支付, but the beneficiary is responsible for the balance of charges after the Plan pays 90 percent of the PPL rate for a service from a non-PPL source.
第三条A. (8) also provides that “[t]he Plan Administrator shall implement such procedures as deemed appropriate to achieve the intent of these co-payments and deductibles.” The in-PPL and non-PPL schedules for co-payments and deductibles encourage employees to use the services of providers who are members of the PPL, 这在本质上有助于降低雇主提供医疗保险的成本. 根据1993年工资协议第XX(12)条, the managed care and cost containment objectives of the PPL program were not intended as “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.“如果雇主没有建立PPL, 它应执行程序，允许其福利计划的受益人支付ppl内的共同付款和免赔额. 否则, the beneficiaries of a benefit plan that does not have a PPL program will be subject to additional costs through higher copayments and deductibles.
支持这一立场, 受益人应该支付较低的自付额和免赔额, 第四条丙. 12. of the 雇主 Benefit Plan provides that if an employer establishes a PPL and if a beneficiary lives outside the area served by the PPL, 受益人对非PPL提供者的共同付款和免赔额应视为在PPL范围内. 这项规定也载于1993年的《皇冠搏彩中心》.
The Complainants’ representative states that the Respondent’s claim processing procedures requires that Employees pay for medical services and then seek reimbursement. The usual procedure for filing claims as contemplated under the terms of the Wage Agreement is one in which the Beneficiary is expected to authorize the provider to bill the insurance carrier for services rendered and pay only the co-payment set forth in 第三条A. (8)直至指定为止
已达到年最大金额. The procedure for claims handling and the method of payment established by the Respondent as described by the Complainants’ representative is inconsistent with the claims procedure contemplated under the terms of the 1993 Wage Agreement and the 雇主 Benefit Plan.
受托人的意见
被申请人被允许(但不是必须)实施PPL计划. 在没有PPL时, 投诉人在使用非PPL供应商时的共同付款和免赔额应被视为在PPL范围内. The Respondent’s procedure for claims handling and its method of payment as described by the Complainants’ representative is inconsistent with the claims procedure contemplated under the terms of the 雇主 Benefit Plan and the 1993 Wage Agreement.