A closer look at some of your health care costs and payments

Your health plan has certain doctors and hospitals in it. With some plans, we'll also pay for a portion of the cost of care received from those who are NOT in your plan. But those doctors and hospitals don't have an agreement with us, so they can charge higher amounts if they want. Balance billing is when they send you a bill for some or all of their fees — which in most cases have to come out of your own pocket. 
 
It's always a good idea to look at the details of your plan or contact us to see if your plan covers care from doctors and hospitals not in your plan. Also, check whether you need your main doctor (also called your primary care physician or PCP) to refer you to other doctors for services to be covered. 
 
You can avoid being balance billed by always going to doctors or hospitals in your plan. If you choose to go to one that isn't, check with them first to see what they charge. And then call us for info on how much of that we may cover.

If you're having an emergency, you need to get care right away. And you don't need to be worrying about what it costs. That's why when you receive emergency care, for example at the emergency room (ER), we cover it the same whether the hospital is in your plan’s network or not.

An emergency is when a medical condition occurs with symptoms that are so severe that a normal person could reasonably expect that immediate medical attention is needed or the condition could result in placing the health of the individual (or, if pregnant, the health of the unborn child) in danger, or cause serious damage to bodily functions, parts, or organs.

 
Reminder, going to the ER for care that is not an emergency is not a good idea, and will likely cost more than care from a non-emergency doctor. Also, if you’re admitted to the hospital from the ER — you need to make sure the hospital and the doctors treating you are in your plan’s network. Some states, but not all, have laws that require the doctors and hospitals to tell you if they are not in your plan’s network. Always, if it's possible, call us or have someone with you call us to check and see if the doctors and hospital are in your plan’s network.

You are required to pay your premium by the scheduled due date. If you do not do so, your coverage could be terminated. After you pay your first premium payment, if you do not pay your future premium payments on time, you will receive a 31-day grace period. A grace period is a time period when your plan will not terminate even though you did not pay your premium. If you do not pay your delinquent premium by the end of the 31-day grace period, your coverage will be terminated.

If you’re getting financial help from the government to pay your health plan, once you’ve paid at least one monthly payment, you can get a grace period of up to three months if you fall behind on payments.

We’ll continue to pay claims for your care for the first month of this grace period. And then where allowed by law, we’ll hold (also called "pend") claims — meaning, we won’t pay them yet, but we’ll keep them and get ready to pay them.

If you're able to pay all the missed monthly payments before your grace period is up, we will then go back and pay any claims for covered services we were holding (also called “pending”).

Reminder: Not all grace periods are three months — this is when you’re getting financial help from the government for your monthly payment.

If you don’t pay for all the missed months, we have to deny any claims that we were holding or pending. And you’ll be responsible to cover those costs.

It’s best to pay your monthly payment on time every month, to avoid any chance of getting into your grace period. Ask about setting up automatic payments if you think that can help you.

Retroactive denial means going back and denying claims that were paid in the past. One way that could happen is if we paid a claim after we got your monthly payment; but then your bank says there’s not enough money in your account and we never get a new payment from you. We’d then go back and retroactively deny that claim, and we’d need to get the money back that we paid for it.

If a claim wasn’t paid yet, but we were just holding it (or pending it) as described in the previous section, Grace period for monthly payments — it can also be denied if you run out your grace period. But since we didn’t pay it yet, we wouldn’t call it a retroactive denial. It’s just called a denial.

One way you can avoid having your claims denied is by always paying your monthly payment on time. If you’re late, be sure to pay before your grace period runs out. Ask about setting up automatic payments if you think that can help you.

If you pay more than what you owe, we'll either refund or credit the extra amount to you or your account. Our systems will notice any overpayment. But if you believe you've paid more than you needed to, please call the member service number on the back of your ID card, or log in to your online account and send us a message. Some health plans will describe this by the official terms "recoupment of overpayments," which means the same thing — getting your money back if you’ve overpaid.

If you and your doctor feel you need a prescription drug that's not on your plan's drug list, please have your doctor or pharmacist get in touch with us. If you would like to start an exception request, please call the Member Service phone number on the back of your ID card. We'll make a decision within 72 hours of getting the request. We will look at whether it's medically necessary and appropriate compared to the other drugs on our list.

If we deny coverage of the drug, you have the right to request an External Review by an Independent Review Organization (IRO). The IRO will make a coverage decision within 72 hours of receiving your request.

You or your doctor may also submit a request for a prescription drug that is not on your plan's drug list based on what's called "exigent circumstances."

For example, if you're suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or if you're undergoing a current course of treatment using a drug not covered by your plan. In that case, we'll make a decision within 24 hours of getting your request.

If we deny coverage for exigent circumstances, you can request an external review by an IRO, similar to above. But a decision will be made more quickly, within 24 hours of getting your request.

An IRO review may be requested by a member, member's representative, or prescribing provider by calling our member services team using the phone number provided on the back of the member’s identification card. A member can also submit a request for an IRO review digitally by completing a form that is available in our message center.

After You receive medical care, You will generally receive an Explanation of Benefits (EOB). The EOB is a summary of the coverage You receive. The EOB is not a bill, but a statement from Us to help You understand the coverage You are receiving.

The EOB shows:

• Total amounts charged for services/supplies received; 
• The amount of the charges satisfied by Your coverage;
• The amount for which You are responsible (if any);
• General information about Your Appeals rights and for information regarding the right to bring an action after the Appeals process.

When you or anybody else on your plan, like your spouse or kids, is covered by two different health plans — both plans need to know about it. We'll work together to make sure you're getting the right benefits. From time to time, you may get a notice asking if anybody is covered by another plan. Not getting this info back to us can delay claim payments. So be sure to let us know as soon as possible.