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Payments to Out-Of-Network Health Care Providers
Health benefit plans administered or insured by ConnectiCare, Inc., ConnectiCare Insurance Company, Inc., and ConnectiCare of Massachusetts, Inc. (“ConnectiCare”) provide out-of-network medical coverage for members. With out-of-network benefits, members may use doctors who are not in the ConnectiCare network of participating providers (“Out-of-Network Providers”). When services are received from Out-of-Network Providers, the ConnectiCare companies will calculate the Maximum Allowable Amount based on either:
A. the discounted charges if the Out-Of-Network Provider is in another network that has an arrangement with the ConnectiCare companies (“Wrap Network”) to provide a discount off charges; or
B. a percentage of the Medicare fee schedule for the services, as determined by ConnectiCare.
As a result of this change, some members may see an increase in their out-of-pocket costs when they receive care from an Out-Of-Network Provider.
Previous Payment Methodology: The HIAA/Ingenix fee schedule
Previously, if your health care plan required payment using HIAA/Ingenix or similar language, we referred to a schedule of provider charges created by Ingenix, Inc., a wholly owned subsidiary of UnitedHealth Group, when determining the maximum amount we paid for such benefits. Ingenix publishes a database called the Prevailing Healthcare Charges System database (“PHCS Database”). The information in this database is updated and published by Ingenix at scheduled times each year.
New Database to Replace HIAA/Ingenix
The Attorney General of the State of New York ("NYAG") initiated an investigation concerning conflicts of interest related to the ownership and use of the PHCS and the fairness of their rates. Under a January 2009 settlement agreement between UnitedHealth Group and the NYAG, the PHCS Database will close and a new, independent database ("New Database") will be established. The New Database will be owned and operated by FAIR Health, Inc., a nonprofit organization selected by the NYAG. Information about FAIR Health is posted on the NYAG's website: http://www.oag.state.ny.us/
After the New Database is operational, FAIR Health will make it available both for research and as a tool for use by health insurance companies to determine out-of-network payment. For more information on FAIR Health visit http://www.fairhealthus.org
The New Database will not be used by ConnectiCare to determine out-of-network benefits effective:
ConnectiCare is affected by the NYAG settlement because we are part of The EmblemHealth companies, which is based in New York. EmblemHealth and other insurers entered into an agreement with the NYAG to switch to the FAIR Health fee schedule.
