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Mid-America Carpenters Regional Council Benefit Funds
Active Plan Health Benefits
The MACRC Active Plan provides comprehensive medical benefits for you and your family, including coverage for hospital & physician services, urgent care services, and even emergency room visits if needed. The Plan also provides for imaging, lab tests, durable medical equipment, skilled nursing, chiropractic care, physical therapy, maternity benefits, coverage for behavioral health, and substance use disorders and more. The Schedule of Benefits outlines the expansive level of coverage available to you and your family. If you lose eligibility, you can choose to continue your coverage under the Low Cost Medical Plan, Click Here to learn more.
What do I pay for medical coverage?
What do I pay for medical coverage?
While you are eligible for benefits under the Active Plan through your employer's contributions, you make no monthly premium payments. However, you are responsible for paying for a portion of the expense until you reach the maximum out of pocket. After that, the Plan pays 100% of covered expenses:
- Deductibles: the amount you must pay every calendar year before any benefits are paid by the Plan.
- Coinsurance: your share of the cost of the medical expenses after you meet the deductible.
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PPO Provider |
Out-of-Network Provider |
| Coinsurance |
80% paid by Plan |
60% paid by Plan |
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Protected Services and Continuing Care Services are payable at the PPO provider rate. |
| Deductible per Calendar Year |
$300 per covered individual
$900 per family
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$600 per covered individual
$1,800 per family
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Are there limits on the amounts I pay out of pocket?
Yes. If you or a family member has a serious illness, you may incur a large number of medical expenses. If that happens, you may meet the out-of-pocket maximum, and then the Plan pays 100% of most covered expenses.
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PPO Provider |
Out-of-Network Provider |
| Out-of-Pocket Maximum per Calendar Year |
$2,300 per covered individual
$6,900 per family
(includes calendar year deductible)
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$6,000 per covered individual
$18,000 per family
(does not include calendar year deductible)
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After a covered individual satisfies the deductible and out-of-pocket maximum, the Plan will pay 100% of most eligible covered services for the remainder of the calendar year. PPO and Non-PPO deductibles and out-of-pocket maximums are separate and cannot be combined. Charges for Protected Services and Continuing Care Services shall accumulate to the PPO Deductible and Out-of-Pocket Maximum.
What if I choose an Out-of-Network Provider?
You will save money by using an in-network PPO provider. If you choose an out-of-network provider, payment by the Plan is limited and the total amount of the claim is subject to a reasonable & customary allowance. This means that if your out-of-network provider charges amounts in excess of reasonable & customary rates, your provider can pursue additional payment from you. Here is an example of how in-network and out-of-network costs compare:
EXAMPLE: Knee replacement surgery
The Reasonable and Customary (R & C) Allowance for a single knee replacement is $54,000
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In-Network BCBS Provider |
Out-of-Network Provider |
| Total Amount of the Claim |
$70,000 |
$70,000 |
| In-Network Discount |
($30,000) |
$0 |
| Total After Discounts |
$40,000 |
$70,000 |
| YOU PAY... |
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| Deductible |
$0 |
$600 |
| Coinsurance (out of pocket max) |
$2,300 |
$6,000 |
| Amount Over R & C Allowance |
$0 |
$16,600* |
| Total You Pay Out of Pocket |
$2,300 |
$22,600 |
*Amounts charged for covered out-of-network medical expenses are subject to the reasonable & customary allowances. In this example, the amount over R & C is $16,000 ($70,000-$54,000), which becomes your responsibility.
What is not covered by the Plan?
There are certain medical expenses that are not covered by the Plan; the comprehensive list of exclusions is outlined in the General Plan Limitations and Exclusions.
BlueCross BlueShield of Illinois (BCBSIL)
BCBSIL administers the PPO network of medical providers. Coverage and out of pocket costs vary depending on if you choose a BCBSIL In-Network PPO Provider or an Out-of-Network Provider. The BlueCross BlueShield of Illinois website can help you find a physician, hospital, or surgi-center in the BCBSIL PPO Network.
The Carpenters Center for Health
Your coverage includes access to the Carpenters Center for Health, a comprehensive health and wellness-focused facility built by carpenters for carpenters. All services provided at the Carpenters Center for Health are FREE. The Health Center website provides additional information on this facility and the team of dedicated professionals waiting to provide you with a better level of care. This site is also your link to the MyPremise member portal. You can schedule appointments at the Health Center, see your test/lab results, send a message to your provider and more!
Lyra Health – Help When You Want It, When You Need It
Lyra Health provides access to care for your emotional and mental health how, when, and where you need it. Lyra’s coaches and therapists can help you feel better and be your best. Active Carpenters, retirees, spouses, and dependents up to age 26, who are eligible and enrolled in medical benefits, have access to 12 free sessions per year. Lyra providers practice evidence-based techniques—therapies that have been tested in scientific studies and proven to work. This means that you can trust you’re getting effective, personalized care. Find more information about Lyra Health at carpenterbenefits.lyrahealth.com, or contact Lyra Health at (877) 368-0644.
Lyra Health replaces the ComPsych GuidanceResources MAP.
Healthcare fraud, waste, and abuse have a negative effect on the healthcare industry and our nation costing billions of dollars each year. Learn more about fraud, waste, and abuse including how to report it here.
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