Why Your Cost may be More when You See a Nonparticipating Provider

HMSA participating providers agree to accept the eligible charge as payment in full for covered services. Nonparticipating providers generally do not. If you receive services from a nonparticipating provider, you are responsible for a copayment plus the difference between the actual charge and the eligible charge in addition to any applicable deductibles.

In some instances, nonparticipating providers charge substantially more than HMSA’s eligible charge. Before receiving services from a nonparticipating provider, ask the provider what the procedure code and charge will be, and then contact HMSA to determine what the eligible charge is. That way, you can calculate in advance what your out-of-pocket cost will be.

Note: You’re responsible for the entire amount charged by your provider for services that aren’t a benefit of your plan. For most plans, the eligible charge doesn’t include excise or other tax. You’re responsible for all taxes related to the medical care you receive.

For more information, see examples of what your copayment would be when you see a nonparticipating provider.