Many GIC members are in health plans that allow the option of going out-of-network for care – going to doctors and hospitals that don’t contract with the plan. If you are in a GIC PPO Plan (Harvard Independence, Tufts Navigator, and UniCare/PLUS), the member share of the out-of-network cost is generally 20 percent; different member costs apply for UniCare/Basic and UniCare/Community Choice. Plan payments are based on “reasonable and customary rates.” (These provisions are outlined in your plan handbook.)
Most medical and mental health plans pay a non-contracted provider based on “reasonable and customary rates,” sometimes called “allowed amounts.” These are the amounts the plans typically pay for the type of services you are receiving. However, be aware that doctors and hospitals often charge the health plan more than the going rate. Depending on the plan and especially out of state, a provider may sometimes bill you for your 20% share plus the difference between what they charge and the plan’s allowed amount, also known as a balance bill. The cost of balance bills can be substantial.
So what can you do to avoid costly balance bills?
- Only visit network medical and mental health/substance abuse doctors and hospitals - providers who have contracts with the plans.
- If you are traveling out of your health plan’s service area or are a full-time student living out-of-state, contact your medical or mental health plan to find out which participating plan providers are in your area. Harvard Independence, UniCare, and United Behavioral Health have national networks that full-time students can use.
- If you do get a balance bill, talk to the provider to see if the provider is willing to negotiate with you on these charges.
Note: For members of the UniCare Indemnity Plan/Basic, although you have benefits with any provider, the possibility of balance billing still exists. Be sure to contact UniCare and United Behavioral Health for the names of network providers in your area that accept the plan’s payments as payment in full.
This information provided by the Group Insurance Commission.