When using out-of-plan benefits, a 50% penalty may be charged for failure to obtain Preauthorization on non-emergency inpatient admissions and elective surgical procedures. This 50% reduction in the approved UCR increases your out-of-pocket expenses. Penalties are not applied to the annual out-of-pocket maximum.
E. OUT-OF-POCKET MAXIMUMS
In each calendar year, you are responsible for a portion of the cost of most benefits. When using In-Plan (HMO) services, your share of the cost is called a co-payment.
On Out-of-Plan (POS) benefits, your share is called co-insurance. There is a maximum out-ofpocket expense for Out-of-Plan services. The contract deductible and all coinsurance amounts count towards your annual maximum. Co-payments for In-Plan benefits, amounts in excess of the UCR, and amounts for non-Covered Services are not applied to the out-of-pocket maximum. Co-insurance paid for any Covered Service obtained under a contract Rider (with the exception of State mandated offers) is also not applied to the out-of-pocket maximum.
For example, if the out-of-pocket maximum is $3,000 per individual or $7,500 per family: When one family Member accumulates $3,000 in Covered Services, the out-of-pocket maximum is met for that individual. However, if the combined expenses in Covered Services of all family Members are in excess of $7,500, then all Members will have met the out-of-pocket maximum, even if no individual Member has incurred at least $3,000.
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.
The “SUMMARY OF BENEFITS” lists all co-payments, deductibles, coinsurance percentages and out-of-pocket maximums applicable to the contract.
With respect to In-Plan Services, it is not anticipated that a Member will make payment, other than any applicable co-payment, to any person or institution providing benefits under the Group Contract. If however the Member furnishes evidence to Atlantis that he or she has made such other payments for Covered Services, payment will be made to the Member.
When using Point-of-Service benefits, claims for out-of-network Covered Services should be submitted directly to Atlantis at 39 Broadway, Suite1240, New York NY 10006. Claims must be received by Atlantis Health Plan, Inc. within 180 days of the date of service. Claims forms are available by calling the Atlantis Member Services Department at 1-866-747-8422.