Noblesville Schools Medical Plan 91 Section 8: General Legal Provisions What Is Your Relationship with Providers and Plan Sponsors? The relationship between you and any provider is that of provider and patient. You are responsible for all of the following: • Choosing your own provider. • Paying, directly to your provider, any amount identified as a participant responsibility, including Copayments, Coinsurance, any deductible and any amount that exceeds the Allowed Amount, when applicable. • Paying, directly to your provider, the cost of any non-Covered Health Care Service. • Deciding if any provider treating you is right for you. This includes Network providers you choose and providers that they refer. • Deciding with your provider what care you should receive. Your provider is solely responsible for the quality of the services provided to you. The relationship between you and the Plan Sponsor is that of employer and employee, Dependent or other classification as defined in the Plan. Notice When the Claims Administrator provides written notice regarding administration of the Plan to an authorized representative of the Plan Sponsor, that notice is deemed notice to all affected Participants and their Enrolled Dependents. The Plan Sponsor is responsible for giving notice to you. Statements by the Plan Sponsor or Participants All statements made by the Plan Sponsor or by a Participant shall, in the absence of fraud, be deemed representations and not warranties. The Claims Administrator will not use any statement made by the Plan Sponsor to void the Plan after it has been in force for two years unless it is a fraudulent statement. Does the Claims Administrator Pay Incentives to Providers? The Claims Administrator pays Network providers through various types of contractual arrangements. Some of these arrangements may include financial incentives to promote the delivery of health care in a cost efficient and effective manner. These financial incentives are not intended to affect your access to health care. Examples of financial incentives for Network providers are: • Bonuses for performance based on factors that may include quality, member satisfaction and/or cost-effectiveness. • Capitation - a group of Network providers receives a monthly payment from the Claims Administrator for each Covered Person who selects a Network provider within the group to perform or coordinate certain health care services. The Network providers receive this monthly payment regardless of whether the cost of providing or arranging to provide the Covered Person's health care is less than or more than the payment. • Bundled payments - certain Network providers receive a bundled payment for a group of Covered Health Care Services for a particular procedure or medical condition. The applicable Copayment and/or Coinsurance will be calculated based on the provider type that received the bundled payment. The Network providers receive these bundled payments regardless of whether the cost of providing or arranging to provide the Covered Person's health care is less than or more than the payment. If you receive follow-up services related to a procedure where a bundled payment is made, an additional Copayment and/or Coinsurance may not be required if such follow-up services