Standard Charges

When you receive emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you should not be charged more than your plan’s copayments, coinsurance and/or deductible.

When you see a health care provider, you may owe out-of-pocket costs, like a copayment, coinsurance, and/or a deductible. If you see a healthcare provider or visit a healthcare facility that is not in your health plan’s network (‘out-of-network”), you may have additional costs or have to pay the entire bill.

Out-of-network providers may be allowed to bill you for the difference between what your health plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit.

“Surprise billing” is an unexpected balance bill. This may happen when you cannot control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network healthcare provider.

Emergency services: You may not be balanced billed if you have an emergency medical condition and get emergency services from an out-of-network healthcare provider or facility. The most they may bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). This includes services you may get after you are in stable condition, unless you give written consent to be balanced billed and give up your protections.

Certain services at an in-network hospital or ambulatory surgical center: When you get services from an in-network hospital or ambulatory surgical center, certain providers may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed.

Learn more about your rights for balance billing.

You may ask for an estimate of the amount that you will be charged for nonemergency medical services provided by a health care provider or facility. Indiana law requires a health care provider or facility to provide an estimate for nonemergency services within 5 business days of receiving a request.

You are never required to give up your protections from balance billing. You also are not required to get out-of network care. You can choose a provider or facility in your health plan’s network.

You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly.

Your health plan generally must:

• Cover emergency services without requiring you to get approval for services in advance (prior authorization).
• Cover emergency services by out-of-network providers.
• Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
• Count any amount you pay for emergency services or out-of-network services toward your in-network deductible and out-of-pocket limit.

If you believe you have been wrongly billed, contact:

Indiana Department of Insurance at https://www.in.gov./idoi/consumer-services/ or 1-317-232-8582 or visit https://www.cms.gov/nosurprises/consumers for more information about your rights under federal law.

Machine-readable files (MRFs) are posted in compliance with the Transparency in Coverage Final Rules (TiC Final Rules). The MRF are required for group health plans and health insurance issuers to disclose on a public website detailed pricing information. Please click on the links below to access this information.

Hawaii Mainland Administrators is an independent third party administrator of a self-funded health plan for Powers Health Group Health Care Plan. Powers Health Group Health Care Plan, who is the plan sponsor, has contracts with local, regional and national Preferred Provider Organizations (PPOs) for negotiated rates with hospitals, doctors, and clinics. Hawaii Mainland Administrators has created a portal as a service to plan sponsors and PPOs, to host the machine readable files that plans are required to publicly provide to facilitate the transparency in coverage rule as mandated by federal law. Please click the link below to go to the portal:

Hawaii Mainland Administrators | Third Party Administrator (TPA) (Hawaii Mainland Administrators - Integrated Payor Solutions)

ComPsych is an independent third party administrator of a self-funded health plan for Powers Health Group Health Care Plan. Powers Health Group Health Care Plan, who is the plan sponsor, has contracts with local, regional and national Preferred Provider Organizations (PPOs) for negotiated rates with hospitals, doctors, and clinics. Hawaii Mainland Administrators has created a portal as a service to plan sponsors and PPOs, to host the machine readable files that plans are required to publicly provide to facilitate the transparency in coverage rule as mandated by federal law. Please click the link below to go to the portal:

Transparency in Coverage (cptransparency.com)