Beginning July 1, 2016
Providers and medical facilities are now either participating or non-participating vs "in-network" and "out-of-network" as they were in the past.
Check Your Provider/Facility Before You Go!
www.askallegiance.com/som or (855) 999-1057
For complete details about State Plan medical coverage, refer to the Summary Plan Document (SPD).
Participating (In and Out-of-State)
Participating providers and facilities have contracted with Allegiance in Montana and Cigna outside of Montana to charge a low, fair rate for your care.
You will pay the following:
- Copays (Copays count toward your max out-of-pocket, but not toward your deductible)
- Montana Health Center - $0 Copay
- Primary Care Office Visit - $25 Copay
- Specialist Office Visit - $35 Copay
- Urgent Care Office Visit - $35 Copay
- Deductible (Counts towards Max Out-of-Pocket) - $1,000 per member per Plan Year
- Benefit % (What the plan pays after you meet your deductible. Counts towards max out-of-pocket.) - 75% after deductible is met, 100% after max out-of-pocket is met
- Max Out-of-Pocket - $4,000/member $8,000/family
In-State Non-Participating providers and facilities have chosen not to sign a contract with Allegiance. If you use non-participating facility or provider in Montana, you pay the cost sharing shown above and the State Plan will pay a fair rate for your care, but the non-participating provider may balance bill you for more. You are responsible for this balance bill and it does not count toward your deductible or max out-of-pocket.)
Out-of-State Non-Participating Cost Sharing
If you go out-of-state and use a non-Cigna provider/facility, the cost sharing is as follows for all services unless stated otherwise in the SPD:
- Annual Deductible (Counts towards Max Out-of-Pocket) - $1,500 per member per Plan Year (This is separate from the $1,000 deductible above)
- Benefit % (What the plan pays after you meet your deductible.) Balance bill does not count towards max out-of-pocket. - 65% + balance billing
- Max Out-of-Pocket - $4,950/member + balance billing, $10,900/family + balance billing (These are separate from annual max out-of-pockets shown above)