Health Plan Reminder: Out-of-Network Providers
This is a general reminder to all employees enrolled in a State health plan.
You are encouraged to use in-network providers to receive the best value from your health plan. No matter which plan you are enrolled in, receiving health care from an out-of-network provider will significantly increase your out-of-pocket medical costs.
Open Access Plans (OAPs): Aetna and HealthLink
The OAP allows you the flexibility to use out-of-network providers in Tier III, but at a much higher out-of-pocket cost. Your Tier III plan reimbursement is based on the plan’s allowable charges (varies by geographic region) and any amounts over the allowable charges do not count toward your plan year out-of-pocket maximum.
You are encouraged to use Tier I and Tier II providers. If you wish to see an out-of-network provider, then prior to receiving health care, you should always contact your OAP to obtain preauthorization of benefits to ensure the services meet medical necessity criteria. You can ask your OAP for an estimate of the amount that the plan will pay if you provide detailed provider and procedure code information from your doctor.
Quality Care Health Plan (QCHP) administered by Aetna
The QCHP allows you to use out-of-network providers, but at a significant out-of-pocket cost. Plan reimbursement is based on the Maximum Reimbursable Charge (MRC), which is the maximum that the plan will allow for any eligible billed services. You are responsible for any portion of the expense that is above MRC. After deductibles are met, the percentage of the claim that will be paid is always based on the MRC amount or the actual billed amount, whichever is less. Amounts above the MRC do not apply to your plan year out-of-pocket maximum.
You are encouraged to use in-network providers. If you wish to see an out-of-network provider, then prior to receiving health care, you should always contact Aetna to complete the pre-determination process to ensure the services meet medical necessity criteria. You can ask Aetna for an estimate of the amount that the plan will pay if you provide detailed provider and procedure code information from your doctor.
Health Maintenance Organizations (HMOs): BlueAdvantage, Aetna, Health Alliance, HMO Illinois
HMOs contract with providers who have agreed to lower their rates and also meet quality standards in order to participate in the HMO. Except for emergency services, generally HMOs WILL NOT COVER services rendered by out-of-network doctors or other non-participating providers. If you are referred to, or choose to see a provider outside of the HMO network, then prior to receiving health care, you must contact the HMO to seek and receive authorization. If prior authorization is not received, then you will be financially responsible for the entire bill.
Consumer Driven Health Plan (CDHP) administered by Aetna
The CDHP allows you to use out-of-network providers, but at a significant out-of-pocket cost. Plan reimbursement is based on allowable charges (varies by geographic region), which is the maximum that the plan will allow for any eligible billed services. You are responsible for any portion of the expense that is above the plan’s allowable charge and these amounts do not count toward your plan year out-of-pocket maximum.
You are encouraged to use in-network providers. If you wish to see an out-of-network provider, then prior to receiving health care, you should always contact Aetna to complete the pre-determination process to ensure the services meet medical necessity criteria. You can ask Aetna for an estimate of the amount that the plan will pay if you provide detailed provider and procedure code information from your doctor.
How to Find In-Network and Participating Health Plan Providers
See your health plan website or call their customer service number listed below. Customer service numbers are also printed on the back of your health plan ID card.
Aetna OAP, HMO, CDHP, and QCHP
Health Alliance HMO
HealthLink OAP
HMO Illinois and BlueAdvantage HMO
Questions?
Contact University Payroll & Benefits (UPB).
