You get your highest benefits and you pay less when you get care from Medica network providers. We’ve negotiated special discounts for you. If you use a provider that’s not in our network, you don’t get the benefit of Medica’s discount. For covered services provided by an out-of-network provider, Medica will pay a fee that may be less than the amount the provider bills. When this happens, you are responsible for paying the difference. Here is an example:
Amount billed | $3,896.00 | $3,896.00 |
| Medica negotiated price | $1,356.29 | |
| Non-Network Fee Medica Pays | | $3,731.00 |
Deductible | None | $500.00 |
Medica pays | $1,085.03
(80% of $1,356.29) | $2,584.80
(non-network fee less
deductible x 80%) |
| Your coinsurance | $271.26
(20% of $1,356.29) | $646.20
(non-network fee less
deductible x 20%) |
| Difference between amount billed and what Medica pays | None | $165.00
(Difference between amount billed and what Medica pays. It does not count towards deductible, coinsurance or out-of-pocket maximum) |
| You pay | $271.26 In-Network | $1,311.20 Out-of-Network |
- First, verify that you have Out-of-Network coverage. Then ask: What is my deductible? What is my coinsurance?
What is my out-of-pocket maximum? How much will I have to pay?
- Will the provider negotiate? Ask if they will accept Medica’s rate.
- Will the Out-of-Network provider submit claims for you? If so, make sure they use the claims address on the back of your Medica ID. If the provider will not submit your claim for you, you should mail it to the same Medica address.
Please note: Claims you submit must include itemized diagnoses and procedure codes from your provider. Keep a copy for your records.
- After your Out-of-Network claim is approved: In most cases, Medica pays its portion of the bill directly to you. You are responsible for paying the out-of-network provider’s entire bill. That includes the amount Medica paid you and all other charges.
When you use Out-of-Network services, you will have an out-of-pocket maximum. However, you will likely pay more than the maximum due to not being able to take advantage of the discounts Medica has with In-Network providers.
Do you want an estimate of the average amount for a procedure? Ask your provider for the procedure (CPT) code, then call Medica Customer Service.
Or, get an online estimate of out-of-pocket costs at MainStreetMedica.com. It’s easy to find In-Network care.
Click Find A Doctor to find network physicians, specialists, clinics and hospitals.
Call Customer Service at the number on your Medica ID card or e-mail us at medicafb@medica.com.