Enrollee Liability Calculation Sample Clauses
Enrollee Liability Calculation. Enrollee liability calculation for covered healthcare services will be based on the lower of either billed covered charges for covered services or negotiated price that the Host Blue makes available to BCBSM that allows Group’s Enrollees access to negotiated participation agreement networks of specified Participating Providers outside of BCBSM’s service area. Under certain circumstances, if BCBSM pays the Healthcare Provider amounts that are the responsibility of the Enrollee, BCBSM may collect such amounts from the Enrollee. In situations where participating agreements allow for bulk settlement reconciliations for Episode-Based Payment/Bundled Payments, BCBSM may include a factor for such settlement or reconciliations as part of the fees BCBSM charges to Group. Where Group agrees to use reference-based benefits, which are service-specific benefit dollar limits for specific procedures, based on a Host Blue’s local market rates, Enrollees will be responsible for the amount that the healthcare Provider bills for a specified procedure above the reference benefit limit for that procedure. For a Participating Provider, that amount will be the difference between the negotiated price and the reference benefit limit. For a Nonparticipating Provider, that amount will be the difference between the Nonparticipating Provider’s billed charge and the reference benefit limit. Where a reference benefit limit exceeds either a negotiated price or a Provider’s billed charge, the Enrollee will incur no liability, other than any applicable Enrollee cost sharing.
Enrollee Liability Calculation a. In General When covered healthcare services are provided outside of BCBSM’s service area by Nonparticipating Providers, the amount an Enrollee pays for such services will generally be based on either the Host Blue’s Nonparticipating Provider local payment or the pricing arrangements required by applicable state law. In these situations, the Enrollee may be responsible for the difference between the amount that the Nonparticipating Provider bills and the payment BCBSM will make for the covered services as set forth in this paragraph. Payments for out-of-network emergency services will be governed by applicable federal and state law.