Transparency in Coverage

For individual consumers

Help for common health insurance issues

Terms and conditions of your health insurance plan may vary based on rules or laws in your state. Please refer to your policy document for more information.

Out-of-network liability and balance billing

In the following situations benefits for care accessed from non-network providers in the United States will be eligible for coverage. The non-network provider is prohibited by law from billing you for any amounts above the network cost-sharing for such benefits:

  1. Benefits for out-of-network emergency services at emergency facilities, except for certain post-stabilization services you have validly consented to;
  2. Benefits for non-emergency services performed by most non-network providers at network health care facilities, unless you have validly consented to those out-of-network services; or
  3. Benefits for air ambulance services from non-network air ambulance providers.

Your rights and protections against surprise medical bills

When you get emergency care, get treated by an out-of-network provider at an in-network hospital, outpatient surgical center, or air ambulance services, you're protected from surprise billing and balance billing.

What is balance billing?

When you see a doctor or other health care provider, you may have to pay certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You also may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn't in your health plan's network.

Balance billing is when out-of-network providers or facilities bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.

"Surprise billing" is an unexpected balance bill. This can happen when you can't control who is involved in your care — like when you see a provider at an in-network facility but are unexpectedly treated by an out-of-network provider and did not consent to the additional charges.

You're protected from balance billing for:

Emergency services

If you get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan's in-network cost-sharing amount (such as copayments and coinsurance). You can't be balance billed for these emergency services. That includes services you may get after you're in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.

Certain services at an in-network hospital or ambulatory surgical center

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

You don't have to give up your protections from balance billing. You also don't have to get out-of-network care. You can choose an in-network facility, and you may be able to choose an in-network health care provider.

You may have more rights under state law. Please refer to your state regulator for more information or call Medica Member Services.

When balance billing isn't allowed, you also have these protections:

  • You're only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
  • Your health plan generally must:
    • Cover emergency services without asking you to get approval for services in advance (prior authorization).
    • Cover emergency services by out-of-network providers.
    • Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit that are protected by the federal No Surprises Act.

If you believe you've been wrongly billed, you may contact the No Surprises Help Desk (NSHD) at 1 (800) 985-3059 or Medica Member Services.

Visit https://www.cms.gov/nosurprises for more information about your rights under federal law.

Enrollee claim submission

A claim is usually when a provider asks an insurance company to pay for your health care services. Usually, providers file claims with us on your behalf. If you got services from an out-of-network provider, and if that provider doesn't submit a claim to us, you can file the claim directly. Claims need to be filed within 365 days from the date of service. Please contact Medica Member Services at the number on the back of your ID card to learn more about the time limit for submitting your claim. To file a claim, follow these steps:

  1. Fill out a claim form
  2. Attach an itemized bill from the provider for the service.
  3. Make a copy for your records.
  4. Mail your claim to the address below.

For medical claims
Medica Claims Department
CW199IFB PO Box 9310
Minneapolis, MN 55440-9310

For prescription claims
Express Scripts
ATTN: Commercial Claims
PO Box 14711
Lexington, KY 40512-4711

Premium payment grace periods

You must pay your premium by the due date. If you don't, your coverage could be terminated at the end of your grace period. A grace period is a time period when your plan will not terminate you even though you didn't pay your premium. For most plans, if you don't pay your premium on time, you'll get a 30-day grace period. Any claims submitted for you while you're in a grace period may be pended. This means that no payment will be made to the provider until your delinquent premium is paid in full. If you don't pay your late premium by the end of the 30-day grace period, your coverage will be terminated. If you pay your full outstanding premium before the end of the grace period, we'll consider payment all claims for covered services you got during the grace period.

If you're enrolled in an individual health care plan offered on the Health Insurance Marketplace and you get an advance premium tax credit, you'll get a three consecutive month grace period, and we'll consider payment for all claims for covered services.

Here's a helpful chart to help you understand your tax credit grace periods.

Federal Tax Credit Grace Period

Premium Payment Information

Claim Information

First month of grace - March

The premium payment is due on March 1. If no payment is made by March 31, March will become the first month of the grace period.

Services (including prescriptions) received in March will be paid by Medica.

Second month of grace - April

If no payment is made for March or April, April becomes the second month of the grace period. You will need to pay the premiums for the months of March and April to cancel the grace period.

We may place claims received in April into a pending status and won't pay them until your total premium due has been satisfied.

Third month of grace - May

If no payment is made for March, April or May, May becomes the third and final month of the grace period. To avoid losing your coverage, you must pay premiums for all three months by May 31.

We may place claims received in May into a pending status and won't pay them until your total premium due has been satisfied.

Coverage ends - June

If you don't pay the total amount due by May 31, Medica will end your coverage March 31.

Claims received after March 31 will not be paid by Medica.

Retroactive denials

A retroactive denial is the reversal of a claim we've already paid. If we retroactively deny a claim we've already paid directly to the provider in full, you'll be responsible for payment.

You might have a retroactive claim denial if:

  • You have a claim that was accidentally paid during the second or third month of a grace period.
  • You have a claim paid for a service for which you weren't eligible.

You can avoid retroactive denials by:

  • Paying your premiums on time and in full.
  • Making sure you talk to your provider about whether the service performed is a covered benefit.
  • Getting your medical services from an in-network provider.

Recoupment of overpayments

Call the Medica Member Services number on the back of your ID card if you believe you've paid too much for your premium and should get a refund.

Drug exception timeframes and enrollee responsibilities

Sometimes our members need prescription drugs that aren't listed on the plan's formulary (drug list). We review these prescription drugs during the formulary exception review process. The member or provider can send the request to us by faxing the Pharmacy Formulary Exception Request form. If the prescription drug is denied, you have the right to an external review.

How to appeal

If you feel we've denied the Pharmacy Formulary Exception Request form incorrectly, you may ask us to submit the case for an external review by an impartial, third-party reviewer known as an Independent Review Organization (IRO). We must follow the IRO's decision. An IRO review may be requested by a member, member's representative, or prescribing provider by:

  • Calling Medica Member Services at the number on the back of your ID card
  • Write to Medica Member Services at:
    Medica
    PO Box 856523
    Minneapolis, MN 55485-6523

For standard exception review of medical requests where the request was denied, the timeframe for review is 72 hours from when we get the request. For expedited exception review requests where the request was denied, the timeframe for review is 24 hours from when we get the request.

To request an expedited review for urgent circumstances, select the "Request for Expedited Review" option in the Request Form.

Explanation of Benefits

Each time we process a claim that you or your health care provider submit to us, we'll explain how we processed it on an Explanation of Benefits (EOB) form.

The EOB isn't a bill. Instead, it explains how your benefits were applied to that particular claim. It includes the date you got the service, the amount billed, the amount covered, the amount we paid, and any balance you're responsible for paying the provider. Each time you get an EOB, review it closely, and compare it to the receipt or statement from the provider.

Coordination of Benefits

Coordination of Benefits (COB), is when you're covered under one or more health insurance plans. An important part of coordinating health care benefits is to determine the order in which the plans pay for them. One plan provides benefits first. This is called the primary plan. The primary plan pays its full benefits as if there were no other plans involved. The other plans then become secondary. Your benefit booklet has more information about COB.

Medical necessity and prior authorization timeframes and enrollee responsibilities

We must approve some services before you get them. This is called prior authorization. If you need a service that we must first approve, your in-network doctor will submit authorization to use. If you don't get prior authorization, you may have to pay up to the full amount of the charges. If you have questions about prior authorization, please call the number on the back of your ID card. Please read the coverage information you get after you enrolled in your health insurance plan. We typically decide on requests for prior authorization for medical services within 72 hours of getting an urgent request or within 15 days for non-urgent requests.

Beginning in 2022, Medica is required to annually share prior authorization data for the previous year by April 1. Minnesota statute 62M.18 outlines this requirement. The following PDF includes the required data for these products:

  • Individual and family business plans
  • Commercial self-insured non-ERISA plans
  • Commercial fully insured (ERISA and non-ERISA) plans
  • Medicare supplement plans

Prior Authorization Turn Around Times

IFB Plan State

Standard Pre-Service

Expedited Pre-Service

Arizona

14 calendar days

72 hours

Iowa

10 business days

72 hours

Kansas

10 business days

72 hours

Minnesota

5 business days

48 hours to include 1 business day1

Missouri

36 hours to include 1 business day2

36 hours to include 1 business day2

Nebraska

15 calendar days

72 hours

North Dakota

15 calendar days

72 hours

Oklahoma

10 business days

72 hours

South Dakota

10 business days

72 hours

Wisconsin

10 business days

72 hours

1 Determination must be made within 48 hours to include one (1) business day after receipt of all necessary information.

2 Determination must be made within 36 hours to include one (1) business day after receipt of all necessary information.

Machine Readable Files

Machine-readable files are a requirement of the Transparency in Coverage Final Rule.

Health insurers are required to publicly display certain health care price information via machine-readable files on their websites beginning in 2022. These machine-readable files will include negotiated rates with in-network providers, allowed amounts for out-of-network providers and may include prescription-drug pricing. 

CMS requires that machine-readable files (MRF) be posted in the JSON format; specifications are provided at https://github.com/CMSgov/price-transparency-guide.

The intended users of MRFs are researchers, regulators, and application developers. MRFs are not intended for member or consumer use. In 2023 members should have access to a user-friendly cost calculator tool with pricing information for 500 "shoppable services", as defined by CMS.

Price Transparency information may not be fully complete at this time. We are actively working to supplement file content.

If you have additional questions, please see the following sites for detailed information (each opens in a new window):

CMS Transparency in Coverage Final Rule Fact Sheet

Transparency In Coverage Final Rule

Tri Agency FAQ 49 (PDF)

CMS.gov Github Repository and Technical Implementation Guide

Search and Download Machine Readable Files

Amounts presented in the Machine Readable files are general, not member-specific or user-specific, per CMS Requirements. They don't include provider taxes, claim edits, deductibles, co-pays and out of pocket maximums which would be applied to a specific member.

Some services described in the Machine Readable files may not be available to everyone due to medical necessity or other restrictions. They are subject to "prerequisites to coverage," that is, conditions such as prior authorization may be needed before the service can be provided.

Medica is using the CMS File Schema (currently V1.1.0) which provides for reporting of negotiated rates at the product level, not the benefit plan level. Some services shown might not apply to all benefit plans within a product. If you need self-insured benefit plan information, please confirm with your Medica account representative the product under which your self-insured plan is included.

Medica works with partners including Leased Networks for some services. Medica does not have visibility to the contracts which our partners have with their providers and is depending partner information being complete and accurate based on our partners' good faith efforts. Medica doesn't have control over whether a given partner's provider is available at any given time.

Information is included for only the services that a provider or facility is licensed to furnish within their scope of service.

Any rates presented in the Machine Readable file for Diagnosis Related Groups (DRGs), also known as Medicare Severity Diagnosis Related Groups (MS-DRGs), All Patient Diagnosis Related Groups (APDRGs) and All Patient Refined Diagnosis Related Groups (APR-DRGs) are based on the current CMS standards. DRGs will vary case by case and patient by patient. In some situations, there are "outliers" to DRGs which may be significantly higher cost than what is shown in the files.

Medica doesn't imply alignment with pricing information furnished by any other payer and does not guarantee that its information to be a basis for comparison with other payers' Machine Readable file data.

Medica contracts using a "Percent of Billed Charges" submitted by providers. We are dependent on submitted claims to be able to determine these In Network Rates. Where providers have never submitted claims against a specific service for which the In Network Rate is a percent of billed charges, we have made a good faith effort to estimate the In Network Rate based on available information including but not limited to comparable rates from CMS and other sources.

If a provider bills a lower rate than what is allowed in the contract, including as a percent of charges, we include that lower rate in the In Network File in order to reflect the current state of the provider billing amounts.

Some Medica products include in network benefits in states outside Medica's usual service area. As applicable, we have included these rates for these services as part of our in network files.

For Allowed Amount (Out of Network) Files: COVID testing under state programs is currently covered by the state. There is no allowed amount paid by or billed to Medica. Therefore these items are not included.

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