Understanding Your Out Of Network Benefits



Understanding Your Out-of-Network Benefits

Some MHN benefit plans cover services received from out-of-network providers; others do not. (For details about your benefits, including copayments, deduct­ibles and exclusions, please refer to your Certificate of Insurance or Summary Plan Description or contact MHN or your benefits manager.)

Even if your plan includes out-of network coverage, there are many benefits to choosing an MHN network provider. One of those benefits is that your out-of-pocket costs are almost always lower when you use an in-network provider because:

• Network providers have agreed to a fee schedule, and for covered services you will only be charged your pre-determined copayment.
• Out-of-network providers are not bound by a fee schedule and can charge whatever they like. Your benefit is based on Maximum Allowable Amounts (MAA) or Usual, Customary and Reasonable (UCR) rates. These amounts are usually less than the provider's billed amount, and out-of-network providers can charge you for the difference.
• If services received from a provider are later determined to be not medically necessary, out-of-network providers may charge you. (MHN network providers may not.)

Find a network provider by clicking here.

Before you receive care from an out-of-network provider:

• Review the examples below of in-network vs. out-of-network costs.
• Read your Certificate of Insurance (COI), Summary Plan Description (SPD) or other plan documentation to understand the details of your out-of-network coverage.
• Know what you might be required to pay. Ask the doctor or facility about their charges and whether they will negotiate a discounted rate with you. Ask if they will allow you to have a scheduled payment plan. Consider using Flexible Spending Account money if you have one.
• Think about getting a second opinion and a price comparison from another doctor or facility.
• Call MHN to verify your benefits and let us know about the care you are going to receive. Some services require notification or approved prior authorization in order to be eligible for coverage.

Examples of In-Network vs. Out-of-Network Costs

Example 1 >> Doctor's Office Visit

	IN-NETWORK CLAIM	OUT-OF-NETWORK CLAIM
Provider's Billed Charges	$200	$200
Reimbursable amount	$160 (MHN contracted amount)	$140 (MAA/UCR*)
Copayment	$15	N/A
Coinsurance	N/A	$28 (20% of MAA/UCR*)
Additional Member Responsibilty	N/A	$60 (Difference between billed charges and MAA/UCR**)
Member's Financial Responsibilty (i.e., what you pay)	$15	$88

Example 2 >> Inpatient Hospital Visit

	IN-NETWORK CLAIM	OUT-OF-NETWORK CLAIM
Provider's Billed Charges	$5,597.40	$5,597.40
Reimbursable amount	$5,020.20 (MHN contracted amount)	$4945.40 (MAA/UCR*)
Copayment	N/A	N/A
Coinsurance	$1,004.04 (20% of MHN contracted amount)	$1,483.62 (30% of MAA/UCR*)
Additional Member Responsibilty	N/A	$652.00 (Difference between billed charges and MAA/UCR**)
Member's Financial Responsibilty (i.e., what you pay)	$1004.04	$2135.62

These are examples are only. They are intended to help you understand the cost difference in general, and they not represent your actual benefits. (For details about your benefits, please refer to your summary plan description or contact MHN or your benefits manager.)

* Some plans use Maximum Allowable Amounts (MAA) for reimbursement and others use Usual, Customary and Reasonable (UCR). MAA and UCR refer to the allowed amount used to process out of network covered claims. Your Certificate of Insurance or Summary Plan Description states which basis for reimbursement is used.

**Differences between billed charges and MAA/UCR are the member's responsibility and do not apply to the annual out-of-pocket maximum accumulation.