What you should know when you use Non-Massachusetts providers
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- Berenice Potter
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1 What you should know when you use Non-Massachusetts providers Frequently Asked Questions For UniCare State Indemnity Plan Basic and PLUS members only Use providers in the UniCare network to avoid balance billing 1. What is balance billing? Balance billing is when a health care provider bills you for the difference between the provider s charge and the amount paid by the UniCare State Indemnity Plan (the allowed amount). For example, if the provider s charge is $100 and the allowed amount is $70, the provider may balance bill you for the remaining $30. The UniCare State Indemnity Plan (UniCare) does not pay provider charges that are above UniCare s allowed amount. UniCare pays providers according to fee schedules that include allowed amounts for payment of services. The allowed amount is the amount UniCare determines to be within the range of payments most often made to similar providers for the same service or supply. By law, Massachusetts providers aren t allowed to balance bill UniCare members. However, providers in other states may do so. For information on how UniCare pays non-network providers outside Massachusetts, see question 13 on page How can I avoid balance billing when I use providers outside Massachusetts? If you live outside of Massachusetts, you won t get balance billed as long as you use providers that are in the UniCare network when you get health care in your home state. Otherwise, you may be balance billed for the difference between UniCare s allowed amount and the provider s charges. Since the Plan doesn t cover balance bills, payment is your responsibility. See question 11 on page 4 about behavioral health providers. If you are a PLUS member living in Connecticut, Maine, New Hampshire or Rhode Island, you can use providers in the UniCare network in your state, as well as PLUS providers in Massachusetts. When you use these network providers in your state, you get the same coverage as you would with Massachusetts PLUS providers. Your dependents who attend school full time outside of Massachusetts can use UniCare Travel Access providers when they need urgent care. They should receive all non-urgent care in their home state to avoid balance billing. See question 6 on page 2. For self-funded plans, claims are administered by UniCare Life & Health Insurance Company. Insurance coverage is provided by UniCare Life & Health Insurance Company. ec714 (Rev. 08/17)
2 3. What do I need to do to use providers in the UniCare network? If you live outside of Massachusetts, you will get a UniCare network ID card (green) and information on how to find network providers in your area. If you do not get this information in the mail, please call UniCare Customer Service at When you use a provider in the UniCare network in your home state, show your UniCare network card, not your UniCare plan ID card (blue). This network card tells the provider that you can use providers in the UniCare network, and they won t balance bill you. Please show your UniCare ID card for visits to all other providers. Don t pay up front for any services, other than any copay that applies. 4. What if I move outside of New England? If you re a PLUS member and are moving outside of New England: Active members contact your GIC Coordinator Retirees and survivors call the Group Insurance Commission (GIC) Tell them you re moving outside New England. They ll let you know about your health plan options. Basic members can live anywhere in the United States. If you move, please give the GIC your new address. Once UniCare gets your new address, we ll send you details about network providers in your new area. 5. What if I return to Massachusetts? If you return to Massachusetts, use your UniCare plan ID card (blue) to get services. Use UniCare Travel Access network providers when you travel to avoid balance billing 6. What happens if I need health care services when I m traveling outside my home state? You can use providers in the UniCare network for urgent care when you travel outside your home state. These network providers are called Travel Access providers. When you use these providers, you won t be balance billed. If you use non-massachusetts providers that aren t Travel Access providers, UniCare will pay these providers based on the fee schedule. Keep in mind that non-travel Access providers can send you a balance bill. To avoid costly balance bills, we suggest you use a Travel Access provider. Your dependents who attend school full time outside of Massachusetts can also use UniCare Travel Access providers when they need urgent care. To avoid balance billing, they should receive all non-urgent care in their home state. When you use Travel Access providers while traveling outside your home state, show your UniCare plan ID card (blue). To find a Travel Access provider, call UniCare Customer Service at Or check the UniCare online Provider Finder (see directions in question 7 on page 3). 2
3 How to find providers in the UniCare network (including Travel Access providers) 7. How can I find a provider in the UniCare network? For a list of providers in the UniCare network, go to the Members page at unicarestateplan.com and select Network Providers for Travelers and Non-Massachusetts Residents (under Quick Links). Read the instructions on the non-massachusetts provider search page about how to use the online Provider Finder. Be sure to select the Travel Access network. You can also call UniCare Customer Service at for help with finding these providers. Important: If you need behavioral health services, you must contact Beacon Health Options (Beacon), the administrator for these services. You may be balance billed if you use a provider that is not in the Beacon network. 8. How can I get my doctor/hospital into the UniCare provider network? Ask your provider to call UniCare Provider Services at for information on how to become a UniCare network provider. Other information you should know when using non-massachusetts providers 9. What happens if I need emergency care in a state other than Massachusetts? If you think you have a life-threatening emergency, call 911 or your area s emergency access telephone number. If you have an emergency that isn t life threatening, call our 24/7 NurseLine at to speak to a registered nurse. In an urgent situation, they can help you decide what to do. If you use a hospital emergency room that is not a UniCare network provider, UniCare will pay the provider based on our fee schedule. The provider may bill you for the balance. We hope and expect that most providers will be reasonable in their demands for payment. But some may try to get the full amount they charged. For more information about how UniCare pays non-network providers, see questions on pages Do I have to notify UniCare if I am admitted to a hospital in the UniCare network? Yes. When you use any hospital inside or outside Massachusetts, you must notify UniCare at
4 11. What if I need behavioral health services? Beacon Health Options (Beacon) administers behavioral health benefits for your health plan. Behavioral health includes mental health, substance use disorder, and Enrollee Assistance Program (EAP) services. Beacon has its own network of providers. If you need behavioral health services, call Beacon toll free at (711 for TTY users). You may be balance billed if you use a psychologist or other behavioral health provider that isn t in the Beacon network. 12. What if I need prescription drugs? CVS Caremark administers prescription drug benefits for your health plan and has its own network of providers. Call CVS Caremark toll free at ( for TTY users). How UniCare pays non-network providers outside Massachusetts 13. If I get services from providers outside Massachusetts that are not in the UniCare network, how will UniCare pay these providers? UniCare pays non-massachusetts providers that are not part of the UniCare network based on fee schedules, rather than paying them for the amount they charge for services provided. These fee schedules are meant to pay providers within the range of payments most often made to similar providers in the area for the same service or supply. We believe our payments are fair. But some providers that are not part of the UniCare network might balance bill you for the difference between the payments made by UniCare according to the fee schedules and the full amount they charge. We hope and expect that most providers will be reasonable in their demands for payment. You are responsible for the amount of the balance bill when you use a non-massachusetts provider that is not in the UniCare network. We suggest you speak with your provider about his or her policies on balance billing. If you are balance billed, you should discuss the charges with your provider because he or she may agree to accept lower payments. If you do get balance billed, you may want to ask your provider to consider accepting UniCare s allowed amount as payment in full for his or her services. You can also give your provider the enclosed communication, UniCare s Fee Schedule Payment Policy for Non-Massachusetts Providers. It tells providers how UniCare pays non-massachusetts providers that are not part of the UniCare network. It also asks them not to balance bill UniCare members. 14. How will I know what to pay if I get balance billed by a provider? The explanation of benefits (EOB) you get from UniCare will let you know how much you need to pay if your provider sends you a bill. 4
5 15. Does this mean I will pay more for the same services? Will this increase my out-of-pocket costs? Non-Massachusetts providers are legally free to balance bill you for the difference between the fee schedule payment amount and the total amount they charge. To avoid possible balance billing, we suggest you use providers in the UniCare network in your home state, or Travel Access network providers while traveling. These network providers will not balance bill you. UniCare State Indemnity Plan P.O. Box 9016 Andover, MA unicarestateplan.com 5
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You can see the specialist you choose without permission from this plan.
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.cvtrust.org or by calling 1-800-288-9870. Important Questions
Coverage for: Individual Plan Type: HMO. Important Questions Answers Why this Matters:
Harford County Public Schools Blue Choice Open Access Coverage Period: 07/01/2015 06/30/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual Plan Type:
The Harvard Pilgrim HMO
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2018 Enrollment Election Form
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$200 per individual; $400 per family
Health New England: SPHS/Mercy Non-Bargaining EPO (EV) Coverage Period: 1/1/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan
Blue Care Elect $250 Deductible MIIA Coverage Period: on or after 07/01/2015
Blue Care Elect $250 Deductible MIIA Coverage Period: on or after 07/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family Plan Type: PPO This
Looking Upwards Value PPO Coverage Period: 04/01/ /31/2017
Important Questions What is the overall deductible? This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document by calling
This health plan meets Minimum Creditable Coverage standards and will satisfy the individual mandate that you have health insurance.
This is a Massachusetts Large Group Plan This health plan meets Minimum Creditable Coverage standards and will satisfy the individual mandate that you have health insurance. Massachusetts Requirement to