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 expenses will be determined and otherwise covered under the Plan.

Eligible expenses are the amount UnitedHealthcare determines that the Plan will pay for benefits.

For designated in-network benefits and in-network benefits for covered health services provided by an in-network provider, except for your cost sharing obligations, you are not responsible for any difference between eligible expenses and the amount the provider bills.

For out-of-network benefits, except as described below, you are responsible for paying, directly to the out-of-network provider, any difference between the amount the provider bills you and the amount UnitedHealthcare will pay for eligible expenses.

For covered health services that are ancillary services received at certain in-network facilities on a non-emergency basis from out-of-network physicians, you are not responsible, and the out-of-network provider may not bill you, for amounts in excess of your applicable copayment, coinsurance or deductible.

For covered health services that are non-ancillary services received at certain in-network facilities on a non-emergency basis from out-of-network physicians who have not satisfied the notice and consent criteria or for unforeseen or urgent medical needs that arise at the time a non-ancillary service is provided for which notice and consent has been satisfied as described below, you are not responsible, and the out-of-network provider may not bill you, for amounts in excess of your applicable copayment, coinsurance or deductible.

For covered health services that are emergency health services provided by an out-of-network provider, you are not responsible, and the out-of-network provider may not bill you, for amounts in excess of your applicable copayment, coinsurance or deductible.

For covered health services that are Air Ambulance services provided by an out-of-network provider, you are not responsible, and the out-of-network provider may not bill you, for amounts in excess of your applicable copayment, coinsurance or deductible which is based on the rates that would apply if the service was provided by an in-network provider.

Eligible expenses are determined in accordance with UnitedHealthcare's reimbursement policy guidelines or as required by law, as described in the SPD.

Designated in-network benefits and in-network benefits

Eligible expenses are based on the following:

When covered health services are received from a designated in-network and in-network provider, Eligible expenses are the UHC contracted fee(s) with that provider.

When covered health services are received from an out-of-network provider as arranged by UnitedHealthcare, including when there is no in-network provider who is reasonably accessible or available to provide covered services, 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.

Out-of-network benefits

When covered health services are received from an out-of-network provider as described below, Eligible expenses are determined as follows:

For non-emergency covered health services received at certain in-network facilities from out-of-network physicians when such services are either ancillary services, or non-ancillary services that have not satisfied the notice and consent criteria of section 2799B-2(d) of the Public Service Act with respect to a visit as defined by the Secretary, the eligible expense is based on one of the following in the order listed below as applicable:

The reimbursement rate as determined by a state All Payer Model Agreement.

The initial payment made by UnitedHealthcare, or the amount subsequently agreed to by the out-of-network provider and UnitedHealthcare.

The amount determined by Independent Dispute Resolution (IDR).

For the purpose of this provision, "certain in-network facilities" are 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.

Important note

For ancillary services, non-ancillary services provided without notice and consent, and non-ancillary services for unforeseen or urgent medical needs that arise at the time a service you are not responsible, and an out-of-network physician may not bill you, for amounts in excess of your applicable copayment, coinsurance or deductible.

For emergency health services provided by an out-of-network provider, the eligible expense is based on one of the following in the order listed below as applicable:

The reimbursement rate as determined by a state All Payer Model Agreement.

The initial payment made by UnitedHealthcare, or the amount subsequently agreed to by the out-of-network provider and UnitedHealthcare.

The amount determined by Independent Dispute Resolution (IDR).

Important note

You are not responsible, and an out-of-network provider may not bill you, for amounts in excess of your applicable copayment, coinsurance or deductible.

For air ambulance transportation provided by an out-of-network provider, the eligible expense is based on one of the following in the order listed below as applicable:

The reimbursement rate as determined by a state All Payer Model Agreement.

The initial payment made by UnitedHealthcare, or the amount subsequently agreed to by the out-of-network provider and UnitedHealthcare.

The amount determined by Independent Dispute Resolution (IDR).

Important note

You are not responsible, and an out-of-network provider may not bill you, for amounts in excess of your copayment, coinsurance or deductible which is based on the rates that would apply if the service was provided by an in-network provider.

When covered health services are received from an out-of-network provider, except as described above, eligible expenses are determined as follows:

An amount negotiated by UnitedHealthcare,

A specific amount required by law (when required by law), or

An amount UnitedHealthcare has determined is typically accepted by a healthcare provider for the same or similar service.

The Plan will not pay excessive charges. You are responsible for paying, directly to the out-of-network provider, the applicable coinsurance, copayment or any deductible. Please contact UnitedHealthcare if you are billed for amounts in excess of your applicable coinsurance, copayment or any deductible to access the Advocacy Services as described below.

Following the conclusion of the Advocacy Services described below, any responsibility to pay more than the eligible expense (which includes your coinsurance, copayment, and deductible) is yours.

Advocacy services

The Plan has contracted with UnitedHealthcare to provide advocacy services on your behalf with respect to non-network providers that have questions about the eligible expenses and how UnitedHealthcare determined those amounts. Please call UnitedHealthcare at the number on your ID card to access these advocacy services, or if you are billed for amounts in excess of your applicable coinsurance or copayment.

In addition, if UnitedHealthcare, or its designee, reasonably concludes that the particular facts and circumstances related to a claim provide justification for reimbursement greater than that which would result from the application of the eligible expense, and UnitedHealthcare, or its designee, determines that it would serve the best interests of the Plan and its employees (including interests in avoiding costs and expenses of disputes over payment of claims), UnitedHealthcare or its designee, may use its sole discretion to increase the eligible expense for that particular claim.

Important note

Out-of-network providers may bill you for any difference between the provider's billed charges and the eligible expense described here. This includes non-Ancillary Services when notice and consent is satisfied as described under section 2799B-2(d) of the Public Health Service Act.

With the out-of-area plan Eligible expenses

Eligible expenses are the amount UnitedHealthcare determines that the Plan will pay for benefits. For covered health services from out-of-network providers, except as described below, you are responsible for paying, directly to the out-of-network provider, any difference between the amount the provider bills you and the amount the Plan will pay.

For covered health services that are non-ancillary services received at certain in-network facilities on a non-emergency basis from out-of-network physicians who have not satisfied the notice and consent criteria or for unforeseen or urgent medical needs that arise at the time a non-ancillary service is provided for which notice and consent has been satisfied, you are not responsible, and the out-of-network provider may not bill you, for amounts in excess of your copayment, coinsurance or deductible which is based on the recognized amount as defined in the SPD.

For covered health services that are air ambulance services provided by an out-of-network provider, you are not responsible, and the out-of-network provider may not bill you, for amounts in excess of your applicable copayment, coinsurance or deductible which is based on the rates that would apply if the service was provided by an in-network provider.

Eligible expenses are determined in accordance with the UnitedHealthcare's reimbursement policy guidelines or as required by law.

When covered health services are received from an out-of-network provider, eligible expenses are determined as follows:

The reimbursement rate as determined by applicable law or by an applicable state All Payer Model Agreement.

The initial payment made by UnitedHealthcare, or the amount subsequently agreed to by the out-of-network provider and UHC.

The amount determined by Independent Dispute Resolution (IDR).

For the purpose of this provision, "certain Network facilities" are 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.

Important notice

For ancillary services, and for non-ancillary services provided without notice and consent, you are not responsible, and an out-of-network physician may not bill you, for amounts in excess of your applicable copayment, coinsurance or deductible which is based on the recognized amount as defined in the SPD.

For emergency health services provided by an out-of-network provider, the eligible expense is based on:

The reimbursement rate as determined by applicable state law or by an applicable state All Payer Model Agreement.

The initial payment made by UnitedHealthcare, or the amount subsequently agreed to by the out-of-network provider and UHC.

The amount determined by Independent Dispute Resolution (IDR).

Important notice

You are not responsible, and an out-of-network provider may not bill you, for amounts in excess of your applicable copayment, coinsurance or deductible which is based on the recognized amount as defined in the SPD.

For air ambulance transportation provided by an out-0f-network provider, the eligible expense is based on:

The reimbursement rate as determined by applicable state law or by an applicable All Payer Model Agreement.

The reimbursement rate as determined by state law.

The initial payment made by UnitedHealthcare, or the amount subsequently agreed to by the out-of-network provider and UHC.

The amount determined by Independent Dispute Resolution (IDR).

Important notice

Except as described above, eligible expenses are based on either of the following:

When covered health services are received from an in-network provider, eligible expenses are UnitedHealthcare's contracted fee(s) with that provider.

When covered health services are received from an out-of-network provider 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.

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 their vendors, affiliates or subcontractors, at UHC's discretion.

If rates have not been negotiated, then one of the following amounts applies based on the claim type:

For covered health services other than pharmaceutical products, eligible expenses are determined based on available data resources of competitive fees in that geographic area.

When covered health services are pharmaceutical products, eligible expenses are determined based on 110% 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.

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.

Important notice