Benefit changes for fully insured groups (51+) to begin July 1

The use of out-of-network (OON) providers works against the triple aim – better health, better experience and better cost – by creating unnecessary costs and potential risks to patient quality and safety. Even though OON claims represent just 10% of all claims at UnitedHealthcare, they place a heavy financial burden on the businesses and members.

Since OON providers are not bound by a contract with UnitedHealthcare, they are not subject to UnitedHealthcare quality standards and are able to charge patients whatever they choose. In addition, some OON providers balance bill members potentially causing anxiety and confusion.

OON coverage change

Beginning with July 1, 2020, new and renewing businesses, UnitedHealthcare will remove the OON benefit for lab, durable medical equipment (DME) and dialysis1 for UnitedHealthcare commercial, fully insured, large group (51+) plan designs in states where:

  • These types of benefit changes are permitted at this time and
  • Regulatory approval to implement the UnitedHealthcare 2020 Certificate of Coverage (COC) has been received for fully insured large groups (51+)2

Please consult the Uniform Modification notice for confirmation of impacted customers and to which services this change will apply. 

Benefit impacts are applied at the market level, and all three OON benefits may not change in your state.

OON coverage for these services is being removed because it is critical for these services to be delivered to UnitedHealthcare members by a provider who meets minimum quality and efficiency standards for network participation. UnitedHealthcare members have access to a broad network of lab, DME and dialysis providers that meet these minimum standards.

Customer impacts

Renewing customers in states where the change is allowed will be notified of the change, and to which services it applies, through the Uniform Modification process. Uniform Modification notices for renewals are available from the UnitedHealthcare sales and support team.

Brokers should consult the Uniform Modification notice for confirmation of impacted customers and to which services this change will apply.

This change applies to outpatient services only. It does not apply to lab tests, DME or dialysis ordered for services provided during an: 

  • Emergency room visit
  • Inpatient or hospital observation stay
  • Outpatient surgical procedure visit 

Note: No other components of the overall OON benefit are impacted.

Member protections

With the removal of the OON benefit for lab, DME and dialysis, a member may be responsible for the entire amount of an OON claim for these services. To protect UnitedHealthcare members from unexpected financial hardship or unnecessary risk, and in accordance with their UnitedHealthcare Participation Agreement, network providers are required to refer UnitedHealthcare members to other network providers.

If a network provider wants to refer a UnitedHealthcare member to an OON provider for non-emergent services, including lab, DME and dialysis facilities, they must either obtain prior approval from UnitedHealthcare for the OON referral or obtain written consent from a member prior to referring the service.

To seek a prior approval for an OON referral, the referring provider or member may contact UnitedHealthcare at the number on the health plan ID card and request prior approval and coverage at the network benefit level based upon geographic or clinical gaps. Due to the broad geographic and service access with UnitedHealthcare’s existing lab, DME and dialysis network, there are rarely gaps that require approval; UnitedHealthcare can refer the member to a network provider.

Impacted member communications

A letter will be mailed to impacted members who have seen an OON Lab, DME or Dialysis provider in the past 12 months.

If a member sees an OON Lab provider after July 1, 2020, an exception letter will also be sent.  Exception letters will only be sent to members who have a qualified OON Lab claim from June 1, through June 30, 2020.

Small group implementation

This benefit change will be implemented for Small Business (2­–50) customers beginning with Jan. 1, 2021, new business and renewals. Additional information will be released closer to the implementation date.

For more information please contact your UnitedHealthcare representative. 

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  1. For members of a NY-situs plan, a limited number of out-of-network dialysis center options will exist for patients meeting certain conditions. Please refer to the plan COC for details.
  2. NY large group: 101+.