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PPO
INFORMATION
Because of the high cost of
medical care, students are searching for health insurance programs
designed to meet their needs and budget.
The SOMA College Medical Insurance Plan has been offered since 1996
to students as an alternative to school programs.
It helps keep health care affordable and provides members with the
freedom to choose any doctor or healthcare provider when Medical care is
needed.
The
SOMA College Medical Insurance Plan is a Preferred Provider Organization (PPO)
Managed Care Health Plan.
A
PPO provides incentives for members to receive care from network doctors,
but also covers a percentage of costs if a patient goes outside the
network. The Managed Care
Network for the SOMA College Medical Insurance Plan is First Health Network. The
doctors and other health care providers who belong to Network are
called Preferred Providers. They
include general practitioners and internists as well as specialists,
hospitals, and other health care facilities.
The Network has Preferred Providers located locally as well as
nationally.
To
find a First Health Network Preferred Provider, you can use online service at
www.firsthealth.com.
You can find out whether a specific provider belongs to
Network or find Preferred Providers practicing in your area.
Using
First Health Network Preferred Providers will save you money because Preferred Providers
agree to accept negotiated fees that may be lower than what Non-Preferred
Providers would charge. Preferred Providers do not charge more than the
negotiated fee for a given service. For
Non-Preferred Providers, the SOMA Plan pays benefits for reasonable and
customary charges only. If a
Non-Preferred Provider charges more than the reasonable charge allowance,
you must pay the difference.
DISCLOSURE
OF LIMITED BENEFITS
WARNING,
LIMITED BENEFITS WILL BE PAID WHEN NON-PARTICIPATING
PROVIDERS ARE USED.
You should be
aware that
when you elect to utilize the services of a non-participating
provider for a covered
service
in non-emergency situations, benefit payments to such
non-participating provider are not
based upon the amount billed.
The basis of your benefit payment will be determined
according to
your policy's fee schedule, usual and customary charge (which is
determined
by comparing charges for similar services adjusted to the
geographical area where the
services are performed), or other method as
defined by the policy.
YOU
CAN EXPECT TO PAY MORE THAN THE COINSURANCE AMOUNT DEFINED IN THE POLICY
AFTER THE PLAN HAS PAID ITS REQUIRED PORTION.
Non-participating
providers may bill members for any amount up to the billed charge after
the plan has paid its
portion of the bill.
Participating providers have agreed
to accept discounted payments
for services with no additional billing to the member other than
co-insurance and deductible amounts.
You may obtain further information about the participating status
or professional providers and information on out-of-pocket expenses
by
calling the toll-free telephone number on your identification card. |
