Learn more about the AFTRA Health Plan with the following Frequently Asked Questions and answers:
Balance billing
What is balance billing?
Balance billing occurs when a health care provider bills you for charges – other than copayments, coinsurance or any amounts that may remain on your annual deductible – which exceed the Health Plan’s reimbursement for a covered service. Network providers are contractually prohibited from balance billing Health Plan participants, but balance billing by non-network providers is common.
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What should I know if I’m visiting a network health care provider?
Benefits paid to a network provider for covered charges are based on a negotiated discounted rate. A network provider should never balance bill you for charges that exceed that negotiated rate. However, network providers should bill you for the following amounts that are to be paid by you, not the Health Plan:
- The copayment, which is $10 per office visit or $100 per hospitalization
- The coinsurance, which is 10% of covered charges, up to the annual out-of-pocket maximum
- Any amount that may remain on your annual network deductible
- The full cost of any charges that are not covered by the Health Plan
When you receive a bill from your network provider, you should compare it to the Explanation of Benefits (EOB) that you receive from AFTRA H&R. You will see the amount of the full charge billed and the network discount deducted from the full charge. This discount is a result of a contract with the Preferred Provider Organization (PPO) network, and it should not be passed on as a charge to you. However, the copayment, deductible and coinsurance amounts, as well as charges for any non-covered services, are due to the provider.
In rare cases, a network provider may mistakenly balance bill a participant for the amount included in the network discount. If this happens, do not pay the portion of the bill that represents the network discount. Also call Participant Services at (800) 562-4690, and AFTRA H&R will notify the PPO network to contact the provider to correct the error.
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What should I know if I’m visiting a non-network health care provider?
While our PPO network protects you from balance billing, you are obligated to pay whatever a non-network provider bills you. The amounts charged by non-network providers can vary significantly, as there are no contractual limits to what they can charge. If you plan to use a non-network provider, it is prudent to inquire about the fees you can expect to be charged before services are rendered. However, if you receive services without prior knowledge of a non-network provider’s fees and you feel that the charges are excessive, it is within your rights to contact the provider to discuss the bill. Even though non-network providers are not contractually or otherwise obligated to do so, some are willing to adjust the charges and/or work out payment plans with their patients.
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How can I avoid balance billing?
Choose health care providers within the AFTRA Health Plan’s PPO network whenever possible. Network health care providers are contractually prohibited from balance billing Health Plan participants. You may search for network providers from at our "Find a provider" Web page.
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