Out-of-Network Reimbursement Methodology

Affected services include non-emergency services from an out-of-network provider, such as scheduled office visits, outpatient services and surgical procedures.

You may have higher out-of-pocket costs. The medical plan (Cigna and UnitedHealthcare) will use 300% of Medicare rates published by the Centers for Medicare & Medicaid Services (CMS) as the basis for the amount allowed for out-of-network claims, also known as “eligible expenses” for out-of-network services. In some cases, 300% of Medicare will be lower than 90th percentile of reasonable and customary, or R&C, (the current methodology). In such cases, your deductible and coinsurance cost share will be lower, but your provider may choose to bill you the difference between their full charges and the allowed amount (known as “balance billing”). Note: balance billing is also permitted under the current 90% percentile of R&C reimbursement methodology. Learn more about out-of-network deductible and coinsurance amounts across the Cigna and UnitedHealthcare plans >

To find an in-network provider or facility, log on to myCigna.com or myUHC.com and use their provider search tool, or call the number on the back of your medical plan ID card. Alternatively, Accolade Health Assistants can help you find in-network providers. Download the Accolade app or call 866-386-0076.

This change does not affect you. This change is applicable only for nonemergency services from a provider or facility that is not in the Cigna or UnitedHealthcare networks.

An out-of-network provider may bill you for the difference between their billed amount and the amount allowed by the medical plan (Cigna and UnitedHealthcare) , also known as “eligible expenses” for out-of-network services. Balance billing is also permitted under the current 90% percentile of “reasonable and customary” charges reimbursement methodology. Note: When using an in-network provider or facility, you have additional protections against balance billing and surprise bills. You have no protections against balance billing when you choose to receive non-emergency services from an out-of-network provider or facility, and this could result in larger out-of-pocket costs for you.

For non-emergency services, it is your responsibility to know whether a provider you choose is in-network with Cigna or UnitedHealthcare. If the provider is not in-network, you may ask the provider to disclose their fees before you receive services and ask them to confirm whether they will balance bill you. Note that not all providers balance bill, so it is important to have that conversation up front with your provider.  Learn more about out-of-network deductible and coinsurance amounts >

See an example of member cost share for a specialist visit at an in-network provider versus an out-of-network provider. For the out-of-network provider, 300% of Medicare yields a lower coinsurance amount, but a higher potential for balance billing. Note that not all providers balance bill, so it is important to discuss billing practices with your provider upfront, before receiving services.

There are two ways to find an in-network provider.

• Option 1: Find an in-network provider or facility by logging on to myCigna.com or myUHC.com and using their provider search tool or call the number on the back of your medical plan ID card to connect with a representative who can help find you an in-network provider.
• Option 2: Contact an Accolade Health Assistant, a free service to help you and your family navigate your health care journey, including finding in-network providers. To contact Accolade, type accolade/ in a Firm browser, visit member.accolade.com when not on a Firm network or call 866-386-0076.

No, unless you believe the services should be considered under surprise billing regulations. Surprise billing protections generally apply for emergency services or unknowingly receiving care from an out-of-provider at an in-network facility. To best protect yourself from large, unexpected bills, you should choose an in-network provider or facility.

No, this change does not affect surprise billing regulations. These regulations protect you if you did not choose to receive care from an out-of-network provider. Your explanation of benefits (EOB) has information if you believe you have received a surprise bill. Note: some out-of-network providers may ask you to waive your surprise billing regulation protections. Discuss billing practices with your provider in advance of receiving services to avoid unexpected costs.