跳到主要内容

无网络福利

由联合会团体的附属公司注册(共同“团结”)的一些医疗保健福利计划(统称“)为曼联成员提供无网络福利。

United提供不同的无网络福利选项,以满足雇主客户和成员的独特需求。客户选择为员工提供哪些计划。并非所有计划都包括无网络福利。

我们如何支付无网络福利?

当审查由网络外提供商提供的服务的付款要求时,联合航空会遵循会员的福利计划。会员的福利计划将说明哪些服务涵盖网络外。(有些服务仅在从网络提供商接收时才被覆盖。)会员的福利计划也将解释如何支付网络外索赔。

网络外福利通常使用下列一个或多个报销数据库、基准或方法来确定网络外索赔的报销金额。F91.


CMS。美国医疗保险和医疗补助服务中心(“CMS”)用于支付向医疗保险加入者提供的特定医疗保健服务(“CMS费率”)所建立和公布的费率和报销方法。使用这个基准的福利计划对相同或类似的服务使用CMS费率的一个百分比。

公平的健康。FAIR运行状况数据库推荐的速率。公平的健康是一家独立的非营利性公司,独立于团结,该公司收集和管理国家最大的私人费用健康保险索赔数据库。公平健康组织他们通过程序代码和地理区域收到的索赔数据。公平的健康还将数据组织成百分位,反映了收费百分比。例如,某个服务的第70百分位数意味着通过同一服务的提供商计费的50%的费用。有关公平健康基准数据库的其他信息,请访问公平健康的网站

  • Viant。viant建议的利率是一个收集和维护设施的健康保险索赔数据库,然后将专有逻辑应用于推荐的汇率。Viant还通过百分位组织其数据。
  • 达成率。联合航空或其供应商在提供服务后与网络外供应商协商的价格。是否有协商费率取决于具体情况和适用的会员福利计划。
  • 共享储蓄计划或第三方网络折扣。有时美国可能有权获得某些第三方与非网络提供商有关的合同和折扣。当该计划适用时,网络外提供商的账单费用将折扣。
  • 制药方法。用于支付由医生或其他医疗保健专业管理的药物的速度。大多数福利计划使用根据发布的收购成本或药品的平均批发价格确定报销金额的方法。这些方法目前由RJ Health Systems,汤森路透社(在其红书中发布)或基于内部制定的药品定价资源来创建。计划可以使用此方法作为偿还这些服务的主要或辅助方法。
  • 其他方法。这些通常使用当福利计划使用的主要方法不可用或没有速率时使用。他们可能包括:
    • 由Optuminsight或使用相对值级别的第三方供应商建立的方法。相对值比例通常基于服务的难度,时间,工作,风险和资源。我们和Optuminsight通过联合律集团的共同所有权是附属公司。
    • 基于来自第三方供应商的信息的费率,该信息可能反映以下一个或多个因素:1)治疗的复杂性或严重性;2)治疗所需的技术和经验水平;或者3)提供医疗服务的提供者的费用和成本。
    • 根据美联航为相同或类似服务向其合同提供商支付的费率,并根据地理位置适当调整。这可以基于合同提供商的中位数或平均费率。
    • 当没有其他方法时,收取的费用的百分之一。

这对成员有何影响?

按照会员的网外福利计划,美联航为某项服务支付的最高金额,有时会低于网外提供商的收费。会员有责任支付自己的网络外费用份额。提供商可向会员收取网络外服务允许的金额与网络外提供商的收费之间的差额(如有)。如果使用协商费率或第三方折扣,提供商不得向成员收取合同费率与提供商收费之间的差额。

我们如何在会员的网络内福利下支付网络外提供商?

在会员的网络内部福利下,可能有时涵盖网络外提供商的服务。当成员在不可用网络提供商时批准网络提供者时,这可能包括当会员接收到紧急服务时,或者在网络提供商处于网络服务中,并且在治疗过程中,从外出接收服务-of-network provider without the member’s knowledge or consent. In these instances, the member’s benefit plan will provide information on the member’s cost share obligation.

支付给网络外供应商的网络内福利通常使用下列一种或多种报销数据库、基准或方法来确定报销金额:

  • CMS。相同或类似服务的CMS速率或CMS速率的百分比。
  • Par值。联合国中位数率向合同提供商支付相同或类似的服务,以适当的地理位置调整。
  • 达成率。联合航空或其供应商在提供服务后与网络外供应商协商的价格。
  • 第三方网络。如上所述,有时美联航可能有权获取某些第三方与网络外提供商签订的合同。如果合同或贴现率低于支付这些索赔的计划基准,则可以使用这些费率。一旦提交索赔,就会评估费率是否可用。
  • iSight数据。由第三方厂商提供的Data iSight工具推荐。Data iSight工具是一种专利定价工具,它根据来自不同支付方、不同年龄、性别和地区的不同患者的数百万份已支付索赔数据,推荐报销金额,反映美国人口普查结果。该工具根据国家基准、区域工资、索引和地理调整等方法建议报销金额。该工具还提供了透明的报告,允许与提供者进行公开对话,讨论工具确定的合理的服务补偿率。有关数据iSight工具的更多信息,请访问数据iSight的网站。

报销政策是否影响报销金额?

对于网络外供应商的报销依据联合航空的报销政策。应用我们的报销政策通常会导致允许金额的减少。联合航空的报销政策一般是基于国家报销规则和决定,以及州政府项目报销政策和要求。最常见的报销规则包括:

  • 如果一个代码描述了一个过程,而提供者为几个过程代码支付费用,我们可以为每个收费代码应用一个包含费用的金额,而不是单独的金额。
  • 如果手术涉及几种不同的程序,则可以通过单一包括主要程序的单一包容量进行一些或全部程序的覆盖范围。一些二级程序可能有资格以50%的报销。
  • 如果不是医生的保健专业人员提供服务,例如医生的助理,则报销金额将低于医生所允许的数额。

我们的报销政策可以在UHCprovider.com/policies。

www.ambest.com","F82":"UnitedHealthcare Global is part of UnitedHealth Group, Incorporated, a Fortune 10 company. Travel assistance services may be provided by or through UnitedHealth Group entities, and/or the UnitedHealthcare Global brand. SafeTrip Insurance Products are underwritten by U.S. Fire Insurance Company and Crum & Forster Segregated Portfolio Company (SPC), which are not related to UnitedHealth Group, Incorporated or the UnitedHealthcare family of companies.","F83":"UnitedHealthcare Life Insurance Company or Golden Rule Insurance Company is the underwriter and Dental Benefit Providers, Inc. is the administrator of these dental plans.","F84":"Personal insurance is not the same as COBRA, so review your COBRA information carefully.","F85":"A terminated employee may be eligible for continuation of coverage under federal or state law. Check with your former employer.","F86":"Bureau of Labor and Statistics, “Labor Statistics from the Current Population Survey,” 2014.","F3":"2014 Website Functionality Benchmark: US Health Insurance Plan Public Sites, Forrester Research, March 2015.","F4":"The coverage term is one day less than 3 years. In SC, plans are three 11-month terms. In IN and OK, plans are three 364-day terms.This coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Affordable Care Act. Be sure to check your policy carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services). Your policy might also have lifetime and/or annual dollar limits on health benefits. If this coverage expires or you lose eligibility for this coverage, you might have to wait until an open enrollment period to get other health insurance coverage.","F5":"Short term health insurance does not qualify as minimum essential coverage as defined in the Affordable Care Act and may not cover all Essential Health Benefits in your state. Signing up for this coverage may result in a tax penalty. Plans are subject to medical underwriting, and do not cover preexisting conditions.","F6":"Premium effective date on date of viewing. Actual premium may be different based upon the situation at the time of application. Optional benefits require an additional premium cost. Products vary by state. Some Short Term plans available as association group insurance only to members of FACT, an independent association. Additional membership fees may be required.","F7":"Premium effective date on date of viewing. Actual premium may be different based upon the situation at the time of application. Products vary by state. 7 HealthiestYou is not an insurance product and is provided by Teladoc®.","F8":"Premium effective date on date of viewing. Actual premium may be different based upon the situation at the time of application. Optional benefits require an additional premium cost. Products vary by state. Some Short Term plans available as association group insurance only to members of FACT, an independent association. Additional membership fees may be required.","F9":"Short term plans are medically underwritten. This coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Affordable Care Act. Be sure to check your policy/certificate carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health benefits (such as hospitalization, emergency services, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services). Your policy/certificate might also have lifetime and/or annual dollar limits on health benefits. If this coverage expires or you lose eligibility for this coverage, you might have to wait until an open enrollment period to get other health insurance coverage. This is not Minimum Essential coverage as defined in the Affordable Care Act and may not cover all Essential Health Benefits in your state. Some Short Term plans are available as association group insurance only to members of FACT, an independent association. Additional membership fees may be required.","F87":"Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s contract renewal with Medicare.","F10":"THIS PLAN PROVIDES LIMITED BENEFITS. This is a supplement to health insurance and is not a substitute for the minimum essential coverage required by the Affordable Care Act (ACA). Lack of major medical coverage (or other minimum essential coverage) may result in an additional payment with your taxes.","F18":"Benefits vary by plan. Check brochure for details.","F14":"Murphy, Brooke. 21 statistics on high-deductible health plans. Becker’s Hospital CFO. May 19, 2016.","F15":"Benefitfocus. The State of Employee Benefits: Insights and Opportunities Based on Behavioral Data. Large Employer Edition, 2016.","F16":"HSAs are not available solely in conjunction with fixed indemnity insurance plans. You must have a qualifying high-deductible health plan to qualify for an HSA.","F11":"These plans are medically underwritten. Benefits are not paid for expenses resulting from preexisting conditions. See specific plans for details.","F88":"This product provides limited benefits. This is a supplemental to health insurance and is not a substitute for major medical coverage.","F17":"National Institute of Dental and Craniofacial Research, National Institutes of Health. Retrieved from https://www.nidcr.nih.gov/datastatistics/finddatabytopic/dentalcaries/","F12":"Some states excluded.","F19":"Benefits must be assigned to providers to receive reduced rates.","F20":"2015 Comparative Price Report Variation in Medical and Hospital Prices by Country. International Federation of Health Plans. Retrieved from http://www.ifhp.com/","F21":"All products require separate applications. Separate policies or certificates are issued.","F22":"Intensive care or critical care hospitalization benefits are subject to a 31-day maximum per confinement. If more than one surgery occurs during any given day, the highest tiered amount is paid.","F23":"Available after a 6-month waiting period.","F24":"Drug discount card is for prescription discounts only. This is not insurance.","F35":"To enroll in a Medicare Advantage plan, you must first be enrolled in Medicare Part A and B.","F36":"You must continue to pay your Medicare Part B premium.","F26":"This applies only if you choose a Silver plan on the federal Health Insurance Marketplace or your state's marketplace.","F27":"Premiums do not count toward deductibles. Usually copays do not count toward deductibles. Check your plan brochure for more information.","F13":"Underwritten by Golden Rule Insurance Company.","F32":"THESE PRODUCTS PROVIDE LIMITED BENEFITS. THESE ARE SUPPLEMENTS TO HEALTH INSURANCE AND ARE NOT A SUBSTITUTE FOR THE MINIMUM ESSENTIAL COVERAGE REQUIRED BY THE AFFORDABLE CARE ACT (ACA). LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. These products provide benefits in a stated amount regardless of the actual expenses incurred.","F33":"Availability varies by state. CO, CT, ID, MI, PA, and TN have Accident ExpenseGuard only.","F34":"Subject to a lifetime maximum.","F89":"CareCredit is offered through Synchrony Bank, who is not an affiliate of UnitedHealthcare and we are not a vendor of Synchrony. By clicking this link to apply for CareCredit you are moving to a 3rd party website. No line of credit is being provided by Golden Rule Insurance Company or by any UnitedHealthcare legal entity.","F2":"Ratings as of 12/18/2020. This worldwide, independent organization reviews insurance companies and other businesses and publishes opinions about them. This rating is an indication of financial strength and stability. For the latest rating, access www.ambest.com.","F1":"UnitedHealth Group Annual Form 10-K for year ended 12/31/20.","F37":"This product provides limited benefits. This coverage provides a Term Life insurance policy with an optional Critical Illness Benefit that pays cash benefits for a qualifying critical illness. Term Life SafeGuard is not major medical or comprehensive health insurance and does not provide the mandated coverage necessary to avoid a penalty under the Affordable Care Act.","F38":"THIS PRODUCT PROVIDES LIMITED BENEFITS. HOSPITAL SAFEGUARD IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR THE MINIMUM ESSENTIAL COVERAGE REQUIRED BY THE AFFORDABLE CARE ACT (ACA). LACK OF MAJOR MEDICAL COVERAGE (OR OTHER MINIMUM ESSENTIAL COVERAGE) MAY RESULT IN AN ADDITIONAL PAYMENT WITH YOUR TAXES. This product provides benefits in a stated amount regardless of the actual expenses incurred.","F39":"Source: American Heart Association, Heart disease and stroke statistics—2016 update: A report from the American Heart Association [published online ahead of print December 16, 2015]. Circulation. doi: 10.1161/CIR.0000000000000350. http://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_480086.pdf.","F40":"Consult your tax advisor; restrictions may apply.","F41":"Gen Re Research. U.S. Critical Illness Insurance Market Survey Summary, Highlights of 2018/2019 Results. Retrieved from https://www.genre.com/knowledge/publications/surveylhci19-en.html","F42":"Diagnosed more than 90 days after effective date to receive full benefit. Benefit is less if diagnosis occurs between 30-90 days.","F43":"Benefits available once every 12 months.","F44":"Product is medically underwritten.","F45":"Optional benefits require an additional premium cost. Products vary by state.","F46":"Waiting periods may apply.","F47":"American Heart Association. 2020 Heart Disease and Stroke Statistical Update Fact Sheet At-a-Glance. Retrieved from https://www.heart.org/-/media/files/about-us/statistics/2020-heart-disease-and-stroke-ucm_505473.pdf?la=en","F48":"Core Access series is underwritten by Independence American Insurance company and administered by The Loomis Company. Golden Rule Insurance Company and Independence American Insurance Company are separate entities and are not responsible for each other’s contractual or financial obligations.","F49":"Based on pharmacy’s usual and customary price. Actual savings may vary.","F50":"Short-term health insurance is medically underwritten and does not cover preexisting conditions. This coverage is not required to comply with certain federal market requirements for health insurance, principally those contained in the Affordable Care Act. Be sure to check your policy/certificate carefully to make sure you are aware of any exclusions or limitations regarding coverage of preexisting conditions or health benefits (such as hospitalization, emergency service, maternity care, preventive care, prescription drugs, and mental health and substance use disorder services). Your policy/certificate might also have lifetime and/or annual dollar limits on health benefits. If this coverage expires or you lose eligibility for this coverage, you might have to wait until open enrollment period to get other health insurance coverage. This is not Minimal Essential Coverage as defined in the Affordable Care Act and may not cover all Essential Health Benefits in your state. Some Short Term Plans available as association group insurance only to members of FACT, an independent association. Additional membership fees may apply.","F51":"Premium amount is expected to change for the second and third policy/certificate terms. Some TriTerm Medical Plans available as association group insurance only to members of FACT, an independent association. Additional membership fees may apply.","F52":"These plans are medically underwritten. Benefits are not paid for expenses resulting from preexisting conditions. See specific plans for details. THIS PLAN PROVIDES LIMITED BENEFITS. THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR THE MINIMUM ESSENTIAL COVERAGE REQUIRED BY THE AFFORDABLE CARE ACT (ACA). Lack of major medical coverage (or other minimum essential coverage) may result in an additional payment with your taxes.","F53":"Coverage varies depending on the dental plan chosen. See brochure for details. If you use an out-of-network dentist, your benefit will either be determined by the reasonable and customary charge or by the network negotiated rate. An out-of-network dentist can bill a patient for any remaining amount up to the billed charge.","F54":"THIS PRODUCT PROVIDES LIMITED BENEFITS. THIS IS AN ACCIDENT POLICY THAT INCLUDES CRITICAL ILLNESS AND ACCIDENTAL DEATH & DISMEMBERMENT BENEFITS. THIS IS A SUPPLEMENT TO HEALTH INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL COVERAGE.","F55":"THIS IS A LIMITED BENEFITS POLICY. IT PAYS FOR BENEFITS FOR CRITICAL ILLNESSES ONLY AND DOES NOT PROVIDE COVERAGE FOR ANY OTHER MEDICAL CONDITIONS. YOU SHOULD MAINTAIN SEPARATE COMPREHENSIVE HEALTH COVERAGE.","F90":"This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year.","F91":"Ingenix, now known as Optum Insight, Inc. (\"Optum Insight\"), is a wholly-owned subsidiary of UnitedHealth Group Incorporated. Under a January 2009 settlement agreement between UnitedHealth Group Incorporated and the New York Attorney General, Ingenix's Databases closed, and United no longer uses any Ingenix Database to pay out-of-network claims."}">

UHOLGLOONBA2

Baidu