Your Choices for Receiving Care
Each time you need care, you choose between:
In-network services received from participating providers
Out-of-network services received from non-participating providers
The Plans pay benefits either way, but at a higher level for in-network care. In addition, participating providers file claims and handle in-network prior authorization requirements for you.
In-network benefits are based on negotiated fees paid to participating providers. When covered health services are received from out-of-network providers, eligible expenses are based on fees that are negotiated with the provider, a percentage of the published rates allowed by Medicare for the same or similar service, or in rare circumstances, 50% of the billed charge or a fee schedule that is determined at the time of service. When reasonable and customary fee guidelines apply, you are responsible for paying the provider for any difference between the reasonable and customary fee and the provider's actual charge.
Emergency services provided by an out-of-network provider will be reimbursed as eligible expenses under the plan.
Covered services provided at certain in-network facilities by an out-of-network physician, when not emergency services, will be reimbursed as eligible expenses under the plan. For these covered services, "certain network facility" is limited to:
a hospital (as defined in 1861(e) of the Social Security Act),
a hospital outpatient department,
a critical access hospital (as defined in 1861(mm)(1) of the Social Security Act),
an ambulatory surgical center as described in section 1833(i)(1)(A) of the Social Security Act, and
any other facility specified by the Secretary.
Air ambulance transport provided by an out-of-network provider will be reimbursed as described under "Eligible Expenses
Depending on the geographic area and the service you receive, you may have access through UnitedHealthcare's Shared Savings Program to out-of-network providers who have agreed to discounts negotiated from their charges on certain claims for covered health services. See the definition of "Shared Savings Program
" in "Medical Plan Definitions
" for additional information.
Out-of-Network Benefit Exception
Most of the healthcare services you need are available within the network. However, if there is no in-network provider within a 20-mile radius of your home ZIP code, you may be eligible for in-network benefits in connection with specific covered health services. UnitedHealthcare must approve any benefits that fall under this exception prior to receipt of care. These benefits are subject to any plan limitations or exclusions outlined in this Benefits Summary.