Eligible Expenses
Eligible expenses are charges for Covered Health Services that are provided while the Plan is in effect, determined according to the definition in "Medical Plan Definitions." For certain covered health services, the Plan will not pay these expenses until you have met your annual deductible. Stryker has delegated to UnitedHealthcare the discretion and authority to decide whether a treatment or supply is a covered health service and how the eligible expense will be determined and otherwise covered under the Plan.
With the UnitedHealthcare Plans
Eligible expenses are the amount UnitedHealthcare determines that the Plan will pay for benefits. For covered services provided by an in-network provider, you are not responsible for any difference between eligible expenses and the amount the provider bills.
For covered services provided by an out-of-network provider (other than emergency health services or services otherwise arranged by UnitedHealthcare), you will be responsible to the out-of-network physician or provider for any amount billed that is greater than the amount UnitedHealthcare determines to be an eligible expense as described below.
For out-of-network benefits, you are responsible for paying, directly to the provider, any difference between the amount the provider bills you and the amount UnitedHealthcare will pay for eligible expenses. Eligible expenses are determined solely in accordance with UnitedHealthcare's reimbursement policy guidelines.
For in-network benefits, eligible expenses are based on the following:
  • When covered services are received from an in-network provider, eligible expenses are UnitedHealthcare's contracted fee(s) with that provider.
  • When covered services are received from an out-of-network provider as a result of an emergency or as arranged by UnitedHealthcare, eligible expenses are an amount negotiated by UnitedHealthcare or an amount permitted by law. Please contact UnitedHealthcare if you are billed for amounts in excess of your applicable coinsurance, copayment or any deductible. The Plan will not pay excessive charges or amounts you are not legally obligated to pay.
For out-of-network benefits, eligible expenses are based on either of the following:
  • When covered services are received from an out-of-network provider, eligible expenses are determined, based on:
    • Negotiated rates agreed to by the out-of-network provider and either UnitedHealthcare or one of UnitedHealthcare's vendors, affiliates or subcontractors, at UnitedHealthcare's discretion.
      • Eligible expenses are determined based on 140% of the published rates allowed by the Centers for Medicare and Medicaid Services (CMS) for Medicare for the same or similar service within the geographic market, with the exception of the following:
        • 50% of CMS for the same or similar laboratory service.
        • 45% of CMS for the same or similar durable medical equipment, or CMS competitive bid rates.
      • When a rate is not published by CMS for the service, UnitedHealthcare uses an available gap methodology to determine a rate for the service as follows:
        • For services other than Pharmaceutical Products, UnitedHealthcare uses a gap methodology established by OptumInsight and/or a third party vendor that uses a relative value scale. The relative value scale is usually based on the difficulty, time, work, risk and resources of the service. If the relative value scale(s) currently in use become no longer available, UnitedHealthcare will use a comparable scale(s). UnitedHealthcare and OptumInsight are related companies through common ownership by UnitedHealth Group. Refer to UnitedHealthcare's website at www.myuhc.com for information regarding the vendor that provides the applicable gap fill relative value scale information.
        • For Pharmaceutical Products, UnitedHealthcare uses gap methodologies that are similar to the pricing methodology used by CMS, and produce fees based on published acquisition costs or average wholesale price for the pharmaceuticals. These methodologies are currently created by RJ Health Systems, Thomson Reuters (published in its Red Book), or UnitedHealthcare based on an internally developed pharmaceutical pricing resource.
      • When a rate is not published by CMS for the service and a gap methodology does not apply to the service, the eligible expense is based on 50% of the provider's billed charge.
UnitedHealthcare updates the CMS published rate data on a regular basis when updated data from CMS becomes available. These updates are typically implemented within 30 to 90 days after CMS updates its data.
IMPORTANT NOTE: Out-of-network providers may bill you for any difference between the provider's billed charges and the eligible expense described here.
Shared Savings Program
With certain out-of-network providers, UnitedHealthcare may obtain a discount to their billed charges through a Shared Savings Program. This discount is usually based on a schedule previously agreed to by the out-of-network provider. When this happens, you may experience lower out-of-pocket amounts. Plan coinsurance and deductibles would still apply to the reduced charge.
Sometimes Plan provisions or administrative practices conflict with the scheduled rate, and a different rate is determined by UnitedHealthcare. In this case the out-of-network provider may bill you for the difference between the billed amount and the rate determined by UnitedHealthcare. If this happens you should call the number on your ID card.
Keep in mind, Shared Savings Program providers are not network providers and are not credentialed by UnitedHealthcare.
With the Out-of-Area Plan
Eligible expenses are the amount UnitedHealthcare determines that the Plan will pay for benefits. For covered health services from out-of-network providers, you are responsible for paying, directly to the provider, any difference between the amount the provider bills you and the amount UnitedHealthcare will pay for eligible expenses. Eligible expenses are determined solely in accordance with UnitedHealthcare's reimbursement policy guidelines.
Eligible expenses are based on the following:
  • When covered services are received from an in-network provider, eligible expenses are UnitedHealthcare's contracted fee(s) with that provider.
  • When covered services are received from an out-of-network provider as a result of an emergency or as arranged by the UnitedHealthcare, Eligible expenses are an amount negotiated by UnitedHealthcare or an amount permitted by law. Please contact UnitedHealthcare if you are billed for amounts in excess of your applicable coinsurance, copayment or any deductible. The Plan will not pay excessive charges or amounts you are not legally obligated to pay.
  • When covered health services are received from an out-of-network provider, eligible expenses are determined, based on:
    • Negotiated rates agreed to by the out-of-network provider and either UnitedHealthcare or one of UnitedHealthcare's vendors, affiliates or subcontractors, at UnitedHealthcare's discretion.
    • If rates have not been negotiated, then one of the following amounts:
      • For Covered Health Services other than Pharmaceutical Products, Eligible Expenses are determined based on available data resources of competitive fees in that geographic area.
      • For Pharmaceutical Products, UnitedHealthcare uses gap methodologies that are similar to the pricing methodology used by CMS, and produce fees based on published acquisition costs or average wholesale price for the pharmaceuticals. These methodologies are currently created by RJ Health Systems, Thomson Reuters (published in its Red Book), or UnitedHealthcare based on an internally developed pharmaceutical pricing resource.
      • When a rate is not published by CMS for the service, UnitedHealthcare uses a gap methodology established by OptumInsight and/or a third party vendor that uses a relative value scale or similar methodology. The relative value scale is usually based on the difficulty, time, work, risk and resources of the service. If the relative value scale currently in use becomes no longer available, UnitedHealthcare will use a comparable scale(s). UnitedHealthcare and OptumInsight are related companies through common ownership by UnitedHealth Group. Refer to UnitedHealthcare's website at [www.myuhc.com] for information regarding the vendor that provides the applicable gap fill relative value scale information.
UnitedHealthcare updates the CMS published rate data on a regular basis when updated data from CMS becomes available. These updates are typically implemented within 30 to 90 days after CMS updates its data.
IMPORTANT NOTE: Out-of-network providers may bill you for any difference between the provider's billed charges and the eligible expense described here.