Out-of-network liability and balance billing

This plan is a Point of Service (POS) Plan. A POS Plan allows a Member the option of obtaining Covered Services from an Out-of-Network Provider without first receiving authorization from the Member’s Primary Care Physician or Health Advantage. However, the POS option is not as effective or advantageous as when the services of In-Network Providers are used. Claims associated with services provided by Out-of-Network Providers may have less advantageous Deductible, Coinsurance and Annual Limitation on Cost Sharing than claims for services of In-Network Providers.

Reimbursement for services by Out-of-Network Providers generally will be less than payment for the same services when provided by an In-Network Provider and could result in substantial out-of-pocket expense. The Out-of-Network Deductible, Coinsurance and Annual Limitation on Cost Sharing set forth in the Schedule of Benefits are applied to the Allowance or Allowable Charges for services and supplies received from an Out-of-Network Provider, unless:

1. Emergency or Imperative Care Services. The Intervention is for Emergency Care or Imperative Care and initial services are provided within forty-eight (48) hours of the onset of the injury or illness, in which case the applicable In-Network Copayment, Coinsurance and Annual Limitation on Cost Sharing apply;
2. Continuity of Care, Prior to Coverage. A member may notify Health Advantage that prior to the effective date of coverage, they were engaged with an Out-of-Network Provider for a scheduled procedure or ongoing treatment otherwise covered under the terms of this Plan, and that a change from such Out-of-Network Provider for such procedure or treatment would be detrimental to their health. If Health Advantage approves coverage for the scheduled procedure or ongoing treatment, benefits will be provided, subject to applicable In-Network Copayments, Coinsurance and Annual Limitation on Cost Sharing to claims for services and supplies rendered by the Out-of-Network Provider for such condition after Health Advantage’s written approval until the procedure or treatment ends or until the end of ninety (90) days, whichever occurs first;
3. Continuity of Care, Pregnancy, Prior to Coverage. A member may request coverage by notifying Health Advantage that prior to the effective date of coverage, the member was receiving obstetrical care from an Out-of-Network Provider for a pregnancy otherwise covered under the terms of this Evidence of Coverage, and that the member is in the third trimester of pregnancy on the effective date of coverage. If Health Advantage approves In-Network coverage for the requested obstetrical care, benefits will be provided, subject to applicable In-Network Copayments, Coinsurance and Annual Limitation on Cost Sharing for services and supplies received from this Out-of-Network Provider after Health Advantage’s written approval and will continue to apply to claims for services and supplies rendered by such Out-of-Network Provider until the completion of the pregnancy, including two (2) months of postnatal visits; ;
4. Provider Leaves Health Advantage Network. A member may request coverage by notifying Health Advantage that their Provider was formerly an In-Network Provider when their ongoing treatment for an acute condition covered under the terms of the Plan began and that they request In-Network benefits for the continuation of such ongoing treatment. If Health Advantage approves coverage for the ongoing treatment, benefits will be provided, subject to applicable In-Network Copayments, Coinsurance and Annual Limitation on Cost Sharing for services and supplies rendered by the Out-of-Network Provider for such condition after Health Advantage’s written approval until the end of the current episode of treatment or until the end of ninety (90) days, whichever occurs first;
5. Provider Leaves Health Advantage Network, Pregnancy. A member may request coverage by notifying Health Advantage that their Provider was formerly an In-Network Provider when they began receiving obstetrical care for a pregnancy covered under the terms of the Plan, and that they were in the third trimester of pregnancy on the date that the Provider left the Health Advantage network. If Health Advantage approves coverage for the requested obstetrical care, benefits will be provided, subject to applicable In-Network Copayments, Coinsurance and Annual Limitation on Cost Sharing, for services and supplies received from this Out-of-Network Provider after Health Advantage’s written approval and will continue to apply to claims for services and supplies rendered by such Out-of-Network Provider until the completion of the pregnancy, including two (2) months of postnatal visits.
6. Out-of-Network Referral. A member can notify Health Advantage prior to receiving a Health Intervention, and if Health Advantage has determined that the required covered services or supplies associated with such Health Intervention are not available from an In-Network Provider and has provided a written approval of in-network coverage for such services or supplies, applicable In-Network Copayments, Coinsurance and Annual Limitation on Cost Sharing will apply to the claims for the services received from the Out-of-Network Provider.

Notification to Health Advantage of requests for coverage of out-of-network services should be made by writing to:

Health Advantage 
Attention: Medical Audit and Review Services
Post Office Box 3688 
Little Rock, Arkansas 72203 

Requests should be received at least 15 working days prior to your receipt of such services or supplies. 

No Balance Billing from In-Network Providers. In-Network Providers are paid directly by Health Advantage and have agreed to accept Health Advantage's payment for Covered Services as payment in full except for the Deductible, Coinsurance, Copayment and any specific benefit limitation, e.g. Home Health visits are limited to 50 per year (Subsection 3.18), if applicable. A Member is responsible for billed charges in excess of Health Advantage’s payment when Providers who are not In-Network Providers render services, except in limited circumstances. This is sometimes referred to as “balance billing” by Out-of-Network providers, and these excess charges could amount to thousands of dollars in additional out of pocket expenses to the Member.