Sometimes, where you get health care—or who provides it—is out of your control. Like when you need emergency care or when an out-of-network provider is involved in your care without your choice. When this happens, the federal No Surprises Act or state surprise billing law may protect you from paying more than your copayment, coinsurance or deductible.
Other times, you might choose an out-of-network provider. If you choose an out-of-network provider, the protections of the No Surprises Act or state surprise billing law won’t apply. But your healthcare benefit plan may still cover part of the cost, depending on your plan’s terms.
This webpage provides a general overview of the federal No Surprises Act and other common out-of-network benefit situations.
When you don’t choose to receive care from an out-of-network provider, but it happens anyway.
When an out-of-network provider is involved in your care without your choice, the No Surprises Act may apply and protect you from certain out-of-pocket costs.
The No Surprises Act applies when you receive the following services:
- Out-of-network emergency services, including air ambulance (but not ground ambulance)
- Out-of-network nonemergency ancillary services provided at a network facility
- Nonemergency nonancillary services provided by an out-of-network provider at a network facility if the out-of-network provider did not get your prior consent as the No Surprises Act requires.
For the above services, your copayment, coinsurance, or deductible must:
- Be the same as it would have been if the service was provided in your plan’s network
- Be based on what your plan would pay a network provider
- Count toward your network deductible
- Count toward your out-of-pocket limit
And, for the above services, the out-of-network provider is prohibited by the No Surprises Act from sending you a Surprise Bill. A Surprise Bill is a bill for an amount that is more than your health plan determines it and you (through your copayment, coinsurance, or deductible) should pay.
So, with the protections of the No Surprises Act, all you have to pay for the above services is your in-network copayment, coinsurance, or deductible.
The No Surprises Act is a federal law. Some states have passed state surprise billing laws which offer similar protections and may apply in lieu of the No Surprises Act. For more information on whether state or federal surprise billing law applies to your claim, check your Explanation of Benefits.
When you choose an out-of-network provider.
When you choose an out-of-network provider, the No Surprises Act or state surprise billing law generally do not apply, and you may face additional out-of-pockets costs, including a Surprise Bill.
But you may still have benefits—some healthcare benefit plans administered or insured by UnitedHealthcare provide benefits for members when they choose an out-of-network provider.
If the No Surprises Act or state surprise billing law does not apply to a claim submitted by an out-of-network provider, United will look to the member’s benefit plan to determine if it is covered and how it should be paid.
If the service is covered, one or more of the following reimbursement databases, benchmarks, or methodologies may be used to establish the reimbursement amount for out-of-network claims. Which option is used depends on various factors, including but not limited to the terms of the healthcare benefit plan, the type of provider, and the type of service.
- CMS. The established and published rates and reimbursement methodologies used by The U.S. Centers for Medicare and Medicaid Services (“CMS”) to pay for specific health care services provided to Medicare enrollees (“CMS rates”). Benefit plans that use this benchmark use a percentage of the CMS rates for the same or similar service.
- FAIR Health. The rate recommended by FAIR Health’s database. FAIR Health is a not-for-profit company, independent of United, that collects data for and manages the nation’s largest database of privately billed health insurance claims. FAIR Health organizes the claims data they receive by procedure code and geographic area. FAIR Health also organizes data into percentiles that reflect the percent of fees billed or allowed. For example, in a distribution of 100 data points of fees billed, the 70th percentile is the value in the 70th position in the lowest-to-highest array of values, meaning that 70 percent of the values are equal to or lower than the 70th percentile value and 30 percent are equal to or higher than the 70th percentile value. For additional information regarding the FAIR Health Benchmark Databases, please visit FAIR Health's website.
- Viant. A rate recommended by Viant, an independent third-party vendor that collects and maintains a database of health insurance claims for facilities, then applies proprietary logic to arrive at a recommended rate. Viant also organizes its data by percentiles.
- Negotiated Rate. The rate UnitedHealthcare or an independent third-party vendor negotiates with an out-of-network provider after the service was provided. Whether a negotiated rate is available depends on the circumstances and applicable member benefit plan.
- Third-Party Network Discounts. Sometimes UnitedHealthcare may have the right to access contracts and discounts that certain independent third parties have with out-of-network providers.
- Pharmaceutical Methodology. The rate used to pay pharmaceuticals administered by a physician or other healthcare professional.
- Other Methodologies.