The Explanation of an EOB
Click HERE for a sample EOB.
Benefits at a Glance
Quick Summary of Your Pipeline Industry Benefit Fund (PIBF) Health Plan Benefits – This is not intended to be a complete explanation of benefits available; nor does it include all plan limitations and/or exclusions. This is a brief description of general benefit information. For complete benefits and limitations/exclusions, please refer to the PIBF Summary Plan Description.
Medical Plan Deductible – The deductible is the portion of healthcare expense you must pay before the PIBF begins to allow payments. Once the $500.00 individual deductible; or $1,000.00 family maximum deductible is met, PIBF will then allow payment as stated in the SPD (Summary Plan Description). Plan deductibles start over every January 1st. A combination of family members can meet the $1,000.00 family maximum deductible; however, $500.00 is the maximum amount any one family Member can count toward meeting the family deductible. Your PIBF plan does not have a co-pay. The patient portion is the deductible and co-insurance.
Out-of-Pocket – Out-of-pocket is the co-insurance amount you are required to pay (20% of in-network or 30% of out-of-network) on covered medical plan expenses processed by the Pipeline Industry Benefit Fund. Deductible, non-covered expense, and amounts exceeding the payable amount on stand-alone benefits are not included in the accumulated out-of-pocket total. Once an individual’s covered medical expenses have met the $5,000.00 in-network or $7,500.00 out-of-network, out-of-pocket limit during a calendar year, all remaining expenses are paid at 100%.
Member Only Benefits
- Death Benefit – $20,000.00 (Active only)
- Dismemberment & Loss of Sight Benefits – $5,000.00/$10,000.00 (Active only)
- Weekly Disability Benefit – $250.00 weekly, up to 26 weeks (Active only)
- Hearing Aid Benefit – $1,000.00 toward the cost of hearing aid(s) (Active only)
- Prescription Welding Hood Lenses – $75.00 every calendar year (Active, COBRA)
- Laser/Lasik Surgery – $1,000.00 toward the cost of vision correction surgery (Active, COBRA)
- Physical Exam Benefit – $200.00 payable every calendar year (Active, COBRA, Retiree)
- Health Reimbursement Arrangement (HRA) – Reimbursement to the Member for a portion of your out-of-pocket healthcare expenses (Active, COBRA, Retiree)
Active & COBRA Plan Deductibles & Coverage for Members & Qualified Dependents
- The PIBF Medical plan has a $500.00 individual deductible or a $1,000.00 family maximum deductible every calendar year. After the deductible, PIBF will pay 80% on in-network expense, or 70% on out-of-network expense up to the individual out-of-pocket maximum of $5,000.00 on in-network expense and $7,500.00 on out-of-network expense. Once the out of pocket has been met during a calendar year, PIBF will then pay charges at 100% for the remainder of that calendar year.
- The PIBF Dental plan will pay 100% of reasonable expense for a cleaning and exam every six (6) months. All other dental services are subject to a $100.00 individual deductible every calendar year. After deductible, PIBF will pay 80% on in-network expense, or 70% on out-of-network expense up to $1,000.00 annually per person (no yearly maximum for children 18 and under).
- The PIBF Vision plan does not have a yearly deductible. The PIBF will pay $200.00 per person toward the cost of a vision exam, refraction, or the purchase of prescription eyeglasses or contact lenses. This benefit is available every calendar year (no yearly maximum for children 18 and under).
- The PIBF pharmacy plan is administered by Sav-Rx and has a $100.00 individual deductible or a $200.00 family maximum deductible every calendar year. After deductible, PIBF will pay 70% on prescriptions purchased at the counter and 80% on prescriptions purchased through the mail service. Effective January 1, 2019, after deductible, PIBF will pay 80% when a 90-day supply for a maintenance prescription is purchased at a participating pharmacy in the Sav-Rx network.
- The pharmacy plan deductible is separate from the PIBF medical plan. Pharmacy plan co-insurance does not accumulate toward the PIBF medical plan out-of-pocket maximum.
Retiree and Retiree with Medicare Plan Deductibles & Coverage for Members and Qualified Dependents
- The Retiree Medical plan has a $500.00 individual deductible or a $1,000.00 family maximum deductible every calendar year. After deductible, PIBF will pay 80% on in-network expense, or 70% on out-of-network expense up to the individual out of pocket maximum of $5,000.00 on in-network expense and $7,500.00 on out-of-network expense. Once the out-of-pocket has been met during a calendar year, PIBF will then pay charges at 100% for the remainder of that calendar year.
- The Retiree with Medicare plan does not have a yearly deductible on any out-patient or office services (the portion of your charges considered under Part B of Medicare). PIBF will pay 80% of the Medicare co-insurance or Medicare Part B deductible. The out-of- pocket maximum on the Retiree with Medicare plan is $5,000.00 per person. Once you have met the out-of-pocket limit, coverage will be at 100% for the remainder of that calendar year.
- The Retiree with Medicare plan has a $500.00 individual deductible every calendar year on in-patient service (when you are admitted to a hospital; the portion of your charges considered under Part A of Medicare). After deductible, PIBF will pay 80% of the Medicare co-insurance or Medicare Part A deductible.
- The Retiree and Retiree with Medicare Pharmacy plan deductible is $250.00 per person, or a $500.00 family maximum every calendar year and is administered by Sav-Rx. After deductible, PIBF will pay 70% on prescriptions purchased at the counter and 80% on prescriptions purchased through the mail service. Effective January 1, 2019, after deductible, PIBF will pay 80% when a 90-day supply for a maintenance prescription is purchased at a participating pharmacy in the Sav-Rx network. The pharmacy plan deductible is separate from the PIBF medical plan.
- The pharmacy plan deductible is separate from the PIBF medical plan. Pharmacy plan co-insurance does not accumulate toward the PIBF medical plan out-of-pocket maximum.
PIBF Coverage on Stand-Alone Benefits is available to Members and qualified dependents under all plans (Active, COBRA, Retiree, Retiree w/Medicare). NOTE: The yearly deductible does not apply to these benefits. The excess or non-covered portion does not apply to the patient’s out-of-pocket limit.
- Chiropractic Benefit – PIBF will pay $25.00 per visit, up to a maximum of $500.00 per person; per calendar year.
- Non-Surgery Related Physical/Occupational Therapy, Biofeedback, or Pulmonary Rehab Benefit – PIBF will pay $50.00 per visit.
- Sterilization Benefit – This benefit is available for the PIBF Member or dependent spouse only. PIBF will pay $500.00 for all expenses related to a Vasectomy.
- Female Sterilization – Subject to medical deductible and co-insurance
3 EASY HRA FILING STEPS
NOTICE: All the required information is taken directly from the PIBF explanation of benefits.
- COMPLETE TOP PORTION OF FORM
- Employee name
- PIBF U.I.D. #
- Patient name (one family Member per form)
- LIST HEALTHCARE EXPENSES
- Service date
- Provider name/Pharmacy name
- PIBF claim number (Medical Claims)
- Member Balance (This is your out-of-pocket expense)
- Itemized pharmacy statement instead of individual RX receipts
- SIGN, DATE AND SUBMIT THE FORM
- HRA filing deadline is April 15th for the previous year.
- It is no longer necessary to send copies of EOBs if you provide the claim number under claim number/expense description column.
- Waiting to file at the end of the year delays processing time. File HRA as charges are incurred throughout the year.
- Due to the large volume of HRA claims being received, HRA claim status cannot be given over the phone. Visit the Member’s section of our website to inquire about the status of your HRA claim. (Allow 4-6 weeks for processing)
More helpful information and forms can be found by visiting the PIBF website.
