Choosing Between In- and Out-of-Network Care
Under Options 1 and 2 of the Medical Plan, you can choose to see any provider, but you'll pay less when you receive your care through your health care company's network of physicians and facilities because network providers have agreed to charge negotiated discounted fees for their services. In addition, the Plan pays a higher rate of coinsurance for in-network care, so your share of charges, if any, is less for in-network care. Lastly, the deductible is lower for in-network care than it is for out-of-network care, so you have to incur less expense before the Medical Plan begins to pay coinsurance for covered expenses.
When you receive in-network care:
- You usually don't have to file any claim forms; your network provider will usually file claims for you.
- Your out-of-pocket expenses will be lower compared to your expenses for the same type of care on an out-of-network basis. In-network doctors have agreed with Aetna and Cigna to charge pre-negotiated fees that are on average lower than the fees charged by doctors outside the network. You cannot be billed for any amounts above those pre-negotiated fees.
When you receive out-of-network care:
- You may need to file a claim form to receive out-of-network benefits. Please see "Filing a Claim for Benefits" for more information.
- Your out-of-pocket costs for medically necessary covered services generally will be higher than if you received in-network care.
Covered services performed by providers not participating in the network will be reimbursed at the out-of-network level of benefits, subject to reasonable and customary (R&C) charges. These charges are based on average claims data in your area and are determined by your health care company to be appropriate fees for medical services. Out-of-network charges are typically higher than the pre-negotiated fees that are covered for in-network care. Please Note: You will be responsible for paying any charges by your out-of-network provider above the R&C amount. Charges in excess of reasonable and customary levels are not considered a covered expense under the Plan, and they therefore do not count toward the deductible or coinsurance maximum.
The Shared Savings Program is a program in which Aetna and Cigna may obtain a discount to an out-of-network provider's billed charges. This discount is obtained by the non-Network provider agreeing to a reduced charge either directly with Aetna or Cigna or with a third party on behalf of Aetna or Cigna. When this happens, you may share in the savings because your out-of-pocket costs (i.e., coinsurance and deductible) are determined using the reduced charge. In addition, the out-of-network provider should not bill you for any amount above the agreed upon reduced charge. If this happens, however, you should call the number on your ID card for either Aetna or Cigna. In some instances, Aetna or Cigna may not obtain a discount. In this case the out-of-network provider may bill you not only for the deductible and coinsurance applicable to the allowed amount determined by Aetna or Cigna under the terms of the Plan, but for all charges above that allowed amount. Out-of-network providers that agree to reduced charges are not credentialed by Aetna or Cigna and are not Network Providers.