2023 Archdiocese of Atlanta Meritain Group Plan Doc - Manual / Resource - Page 33
GROUP MEDICAL PLAN
GENERAL OVERVIEW OF THE MEDICAL PLAN
The Medical Plan Sponsor has entered into an agreement with Aetna Choice® POS II (the “Network”). This Network
offers you health care services at discounted rates. Using a Network provider will normally result in a lower cost to
the Medical Plan as well as a lower cost to you. There is no requirement for anyone to seek care from a provider
who participates in the Network. The choice of provider is entirely up to you.
Non-Participating Provider Exceptions
Covered services rendered by a Non-Participating Provider will be paid at the Participating Provider level
when a:
(1)
Covered Person has a Medical Emergency requiring immediate care, including any services rendered in a
Hospital Emergency Room or an Independent Freestanding Emergency Department, and emergency
transportation via ambulance or air ambulance.
(2)
Non-Participating Provider provides services at a Network facility.
(3)
Participating Provider submits specimens and x-rays to a Non-Participating Provider.
(4)
Referral is made by a Participating Provider to receive services from a Non-Participating Provider,
subject to Usual and Customary Charges.
(5)
Covered Person receives medical supplies for which there is no Network Provider available.
(6)
Covered Person receives services from a Network surgeon who uses a non-Network facility.
(7)
Covered Person receives professional services which are not available within 30 miles of the Network
area.
(8)
Covered Person resides more than 30 miles outside Network area.
Not all providers based in Network Hospitals or medical facilities are Participating Providers. It is important when
you enter a Hospital or medical facility that you request that ALL Physician services be performed by Participating
Providers. By doing this, you will always receive the greater Participating Provider level of benefits.
Please note, in compliance with the No Surprises Act, when you receive the services described in (1) and (2) above
from a Non-Participating Provider, you should not have to pay more than the Plan’s copay, coinsurance, or
deductible for the same service from a Participating Provider. Any amount you pay for these services shall be
accumulated toward your deductible and Out-of-Pocket Maximum. You should not receive any type of balance bill
(also known as a Surprise Bill) from a Non-Participating Provider for these services. Balance billing occurs when
Non-Participating Providers who do not have a contract with the Health Plan bills you for the difference between
what the Plan will pay and the full amount charged for a service.
Under the No Surprises Act, Medical Emergency services also include: (1) an appropriate medical screening
examination that is within the capacity of the Hospital Emergency Room or of an Independent Freestanding
Emergency Department (“Emergency Departments”), including those ancillary services routinely available the
Emergency Departments to evaluate whether a Medical Emergency exists; (2) such further medical examination
and treatment as may be required to stabilize the individual (regardless of the department of Hospital in which the
further medical examination and treatment is furnished) within the capabilities of the staff and facilities available;
and (3) pre-stabilization services that are provided after the patients are moved out of the Emergency Departments.
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