If you are 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 services from an out-of-network provider will significantly increase your out-of-pocket medical costs.
Open Access Plans (OAP): Coventry and HealthLink
Your OAP allows you the flexibility to use out-of-network providers in Tier III, but this results in a much higher out-of-pocket expense for you. Your Tier III plan reimbursement is determined by the Maximum Allowable Charge (MAC) based on Medicare rates in a geographical location. Medicare reimbursement rates are very low and the OAPs pay only 60% of the MAC after any copayment.
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 services, you should always contact the OAP to obtain preauthorization of benefits to ensure the services meet medical necessity criteria. Your OAP will provide an MAC estimate if you provide detailed provider and procedure code information from your doctor. This cost estimate will help you decide whether or not to receive services from an out-of-network provider.
Quality Care Health Plan (QCHP) administered by Cigna
The QCHP allows you to use out-of-network providers, but this results in significant out-of-pocket expense for you. Plan reimbursement is determined by the Maximum Reimbursable Charge (MRC) based on Medicare rates in a geographical location. Medicare reimbursement rates are very low and the plan pays only 60% of the MRC after plan deductibles are met.
You are encouraged to use in-network providers. If you wish to see an out-of-network provider, then prior to receiving services, you should always contact Cigna to complete the pre-determination process to ensure the services meet medical necessity criteria. Cigna will provide an MRC estimate if you provide detailed provider and procedure code information from your doctor. This cost estimate will help you decide whether or not to receive services from an out-of-network provider.
Health Maintenance Organizations (HMOs): BlueAdvantage, Coventry, Health Alliance, HMO Illinois
Your HMO has contracted 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 non-participating providers. If you are referred to, or choose to see a provider outside of the HMO network, then prior to receiving services, you should always contact the HMO to receive authorization. If prior authorization is not received before you see a non-participating provider, you will be financially responsible for the entire bill.
How to Find In-network and Participating Health Plan Providers
View your health plan website or call their customer service number. See the links to and instructions for navigating plan websites on the Health Plan Provider Directories web page. Customer service numbers are also printed on the back of your health plan ID card.
Coventry OAP and HMO
800-431-1211 or www.chcillinois.com
Health Alliance HMO
800-851-3379 or www.healthalliance.org/stateofillinois
HealthLink OAP
800-624-2356 or www.healthlink.com/illinois_index.asp
HMO Illinois and BlueAdvantage HMO
800-868-9520 or www.bcbsil.com/stateofillinois
Quality Care Health Plan (QCHP)
800-962-0051 or www.cigna.com/stateofil
Questions?
Contact University Payroll and Benefits (UPB).
- Email: benefits@uillinois.edu
- Urbana: 217-333-3111
- Chicago: 312-996-6471
- Springfield: 217-206-7144 or 217-206-7211
