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Disclosures to Members in New Jersey Fully Insured Plans Regarding Out-of-Network Treatment

This summary provides an overview of how your health benefit plan covers out-of-network treatment. It is only guidance to help you understand how in-network benefits cover services you may receive from an out-of-network provider, and it does not alter coverage in any way.

You should refer to your policy for more information about coverages and costs for in-network treatment and whether your plan has other out-of-network benefits.

Coverage of Medically Necessary Treatment on an Emergency or Urgent Basis by Out-Of-Network Health Care Professionals/Facilities

What this Means:

  • Emergency - You are covered for out-of-network treatment for a medical condition manifesting itself by acute symptoms of sufficient severity including, but not limited to, severe pain, psychiatric disturbances and/or symptoms of Substance Use Disorder such that a prudent layperson, who possesses an average knowledge of health and medicine, could expect the absence of immediate medical attention to result in: placing the health of the individual or unborn child in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. This includes any further medical examination and such treatment as may be required to stabilize the medical condition. This also includes if there is inadequate time to affect a safe transfer of a pregnant woman to another hospital before delivery or such transfer may pose a threat to the health or safety of the woman or unborn child.
  • Urgent - You are covered for out-of-network treatment of a non-life-threatening condition that requires care by a health care professional within 24 hours.

Protections under New Jersey Law:

  • Except as discussed below, you should not be billed by an out-of-network health care professional or facility for any amount in excess of any deductible, copayment, or coinsurance amounts (also known as "cost-sharing") applicable to the same services when received in-network. If you receive a bill for any other amount, please call the toll-free member phone number on your health plan ID card, and/or file a complaint with the Department of Banking and Insurance: https://www.state.nj.us/dobi/consumer.htmOpens a new window
  • Your carrier and the out-of-network health care professional/facility may negotiate and settle on an amount that is ultimately paid for the emergent/urgent medical services. If that negotiated amount exceeds what was indicated on the initial Explanation of Benefits, your out-of-pocket cost-sharing may increase above the amount indicated on the initial Explanation of Benefits. Your total final costs will be provided on the Final Explanation of Benefits if settled.
  • If an agreement cannot be reached, your carrier or the out-of-network health care professional/facility may seek to enter into binding arbitration to determine the amount to be paid for the medical services. The amount awarded by the arbitrator may exceed what the carrier has already paid to the out-of-network health care professional/facility; however, any additional amount paid by the carrier pursuant to the arbitration award will not increase your cost-sharing above the amount indicated as your responsibility on the Pre-Arbitration Explanation of Benefits associated with the last payment made to the health care professional/facility before any arbitration. If arbitration is conducted, you will also receive a Final Explanation of Benefits that will show the total allowed charge for the service(s).

Coverage of Inadvertent Out-Of-Network Services

What this means:

  • You are covered for treatment by an out-of-network health care professional for covered services when you use an in-network health care facility ( e.g. hospital, ambulatory surgery center, etc.) and, for any reason, in-network health care services are unavailable or provided by an out-of-network health care professional in that in-network facility. This includes laboratory testing ordered by an in-network health care professional and performed by an out-of-network bio-analytical laboratory (e.g., imaging, x-rays, blood tests, and anesthesia).

Protections under New Jersey Law:

  • Except as provided below, you should not be billed by an out-of-network health care professional or facility, for any amount in excess of any deductible, copayment, or coinsurance amounts (also known as "cost-sharing") applicable to the same services when received in-network. If you receive a bill for any other amount, please call the member phone number on your ID card,  and/or file a complaint with the Department of Banking and Insurance: https://www.state.nj.us/dobi/consumer.htmOpens a new window
  • Your carrier and the out-of-network health care professional/facility may negotiate and settle on an amount that is ultimately paid for the inadvertent out-of-network services. If that negotiated amount exceeds what was indicated on the initial Explanation of Benefits, your out-of-pocket cost-sharing may increase above the amount indicated on the initial Explanation of Benefits. Your total final costs will be provided on the Final Explanation of Benefits if settled.
  • If an agreement cannot be reached, your carrier or the out-of-network health care professional/facility may seek to enter into binding arbitration to determine the amount to be paid for the inadvertent out-of-network services. The amount awarded by the arbitrator may exceed what the carrier has already paid to an out-of-network health care professional/facility; however, any additional amount paid by the carrier pursuant to the arbitration award will not increase your cost-sharing above the amount indicated as your responsibility on the Pre-Arbitration Explanation of Benefits associated with the last payment made to the health care professional/facility before any arbitration. If arbitration is conducted, you will also receive a Final Explanation of Benefits that will show the total allowed charge for the service(s).

Coverage of Treatment from Out-Of-Network Health Care Professionals/Facilities if In-Network Health Care Professionals/Facilities are Unavailable

What this means:

  • Plans are required to have adequate networks to provide you with access to professionals/facilities within certain time/distance requirements so you can obtain medically necessary treatment of all illnesses or injuries covered by your plan.

Protections under New Jersey Law:

  • You can request treatment from an out-of-network health care professional/facility when an in-network health care professional/facility is unavailable, through an appeal, often called a request for an "in-plan exception." Please see the Department of Banking and Insurance's guide at: https://nj.gov/dobi/appeal/Opens a new window

For additional information, including whether a health care professional or facility is in-network or out-of-network, examples of out-of-network costs and estimates for specific services, please sign in to myuhc.comOpens a new window, or call the toll-free phone number on your health plan ID card, 8:00 a.m. to midnight ET, 7 days a week.

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