A New Rider to Your Empire Policy Changes Reimbursement for Covered Services
A new Rider changes what is paid for some covered services
The new Rider to your policy applies starting in 2012 when your group renews your policy. We want you to know about changes in how we reimburse (pay) claims for certain covered services under your policy. It is important because it may change what you owe for covered services.
The Rider changes:
| Some terms that affect the amount Empire allows for covered services offered by In-Network and Out-of-Network health care providers. That amount will now be called the “Maximum Allowed Amount” in your policy. The new Rider explains the Maximum Allowed Amount and how it is determined.|
| How we pay Out-of-Network doctors and other health care services claims. |
| How we figure Out-of-Network claim payment amounts. We will now use a percentage of the National Medicare Physician Fee Schedule to determine this amount. This applies to professional claims such as claims for physician services. |
| When anesthesia services are covered if you need surgery.|
| How certain services will be paid to Out-of-Network health care providers who work for an in-network facility such as a hospital. |
NOTE: For EPO and HMO products, Out-of-Network services are covered only in an emergency, or in rare cases, if Empire approves the services.
What this means to you
The way we pay for Out-of-Network services under your policy is changing. We will now determine claim payments for professional services based on the Medicare Physician Fee Schedule.
This may increase the amount you pay for services from doctors outside our network. This is because you pay a part of the Maximum Allowed Amount if you owe coinsurance or have not yet met your deductible.
The Maximum Allowed Amount may vary if the provider is In-Network or Out-of-Network. Members may be required to pay the difference between the Maximum Allowed Amount and the out-of-network provider’s full charges. Remember, EPO and HMO members are covered for in-network services only, with very limited exceptions.
If you want to learn more
We’re also mailing this information and the rider to your employer. If you have questions, please talk with your group benefits administrator. You can also call Member Services at the number on the back of your member ID card. Please review your Empire policy and riders for the complete terms of your plan.