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When accessing out-of-plan benefits, you will be financially responsible for a percentage of the service after reaching your deductible. In general, the amount that you are responsible for is 20% plus the balance after Atlantis pays Usual, Customary or Reasonable (UCR) charges. In other words, for each service that is provided out-of-plan, Atlantis will pay 80% of the amount approved for that service and you will be responsible for the balance. For example:
Provider Service Charge $300.00
Approved UCR $250.00
Atlantis Payment (80% of UCR) $200.00
Member Responsibility (After Deductible) $100.00
Please refer to your Summary of Benefits for coinsurance amounts that are applicable to specific benefits.
A 50% penalty may be charged for failure to obtain Pre-authorization on non-emergency inpatient admissions and elective surgical procedures. This 50% reduction in benefits is taken after calculating the available benefit, including any deductible and or coinsurance. Penalties are not applied to the annual out-of-pocket maximum.
In each calendar year, you are responsible for a portion of the cost of most benefits. When using In-Plan services, your share of the cost is called a co-payment.
On Out-of-Plan benefits, your share is called co-insurance. There is a maximum out-of-pocket expense for Out-of-Plan services. The Contract deductible and all coinsurance amounts count towards your annual maximum. The prescription drug deductible and In-Plan copayments are not applied. Please refer to the Schedule of Benefits for the amount of your out-of-pocket maximum.
Once the out-of-pocket Maximum is reached for a calendar year, we pay 100% of the Usual, Customary or Reasonable charge for Covered Services for that calendar year.
Please refer to the Restrictions, Exclusions, and Limitations section of your AHP Subscriber Contract for a complete description of restrictions, exclusions and limitations to your benefits.