APWU Health Plan FAQ

Your rights and protections against surprise medical bills 

When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. 

What is “balance billing” (sometimes called “surprise billing”)? 

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You 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 plan’s network. See Sections 1 and 3 of your health plan brochure. 

“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit. See Section 4 of your health plan brochure. “Surprise billing” is an unexpected balance bill as defined by a new federal law called the No Surprises Act. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider. 

The No Surprises Act protects you from surprise balance billing for: 

Emergency services 

If you have an emergency medical condition and 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). Your health plan will pay the out-of-network provider the amount owed in accordance with the No Surprises Act. 

You can’t be balance billed for these emergency services. This 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 

When you get covered services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. Your health plan will pay the out-of-network provider the amount owed in accordance with the No Surprises Act. 

These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. 

If you get other covered services at these in-network facilities, for example from your surgeon or oncologist, those out-of-network providers can’t balance bill you unless you give written consent and give up your protections. 

You’re never required to give up your protections from balance billing under the No Surprises Act. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network. See Section 4 of your health plan brochure. 

When balance billing isn’t allowed, you also have the following protections

You are 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 requiring you to get approval for services in advance (prior authorization). 
• Cover emergency services by out-of-network providers. 
• Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits. 
• Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit. 

If you believe you’ve been wrongly billed, you may contact the U.S. Department of Labor, Employee Benefits Security Administration: 1-866-666-9272 or 200 Constitution Avenue NW, Washington, DC, 20210. 

Learn more about the No Surprises Act and your rights under federal law.

If you have more than one health plan, contact APWU Health Plan to let us know about your coverage. 

When more than one insurance plan could potentially cover your medical expenses, one plan usually pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. 

APWU Health Plan uses guidelines from the National Association of Insurance Commissioners (NAIC) to determine which coverage is primary. 

What is coordination of benefits? 

Coordination of benefits (COB) is the process insurance companies use to decide who is responsible for covering the cost of your care when two insurance plans are working together to pay the same claim. 

COB helps insurance companies: 

• Establish which plan is primary and which is secondary 
• Avoid duplicate payments 
• Make sure two plans don’t pay more than the total amount of the claim 
• Help reduce the cost of health insurance premiums 

Coordinating benefits with Medicare and other coverage 

Section 9 of the Plan brochure provides detailed information about the process APWU Health Plan uses to coordinate benefits with Medicare and other types of insurance. You can find COB details for how your claim will be handled in a range of situations: 

• When you have other health coverage 
• When other government agencies are responsible for your care 
• When others are responsible for injuries 
• When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) 
• When you have Medicare 

Contact APWU Health Plan with questions about coordinating your benefits 

Navigating the healthcare system can be confusing. The customer service team at APWU Health Plan is here to answer your questions and clarify the process, so you can be sure you have the coverage you need. 

To speak with a customer service representative, call: 

1-800-222-2798
1-800-622-2511 (TTY)
8:30 am – 6:30 pm ET
Monday – Friday 

Yes, Virtual Visits let you connect with a doctor by phone or video.¹ Doctors can treat a wide range of health conditions—including many of the same conditions as an emergency room (ER) or urgent care—and may even prescribe medications.² 

Virtual Visits are good for a wide range of issues, including: 

• Allergies  
• Bronchitis 
• Colds 
• Flu  
• Migraines 
• Pink eye 
• Rashes 
• Sinus infections 
• Urinary tract infections 

High Option members: Your first two Teladoc Virtual Visits are free. After that, you have a copay of just $10 per visit. 

Consumer Driven Option members: You’ll pay 15% of the Plan allowance for a Virtual Visit through Amwell, Teladoc, and Doctor on Demand, less than the cost of an in-person office visit. To get started, log in to your myuhc.com member portal. 

Call 911 immediately or go to the nearest emergency room if you believe you are experiencing a medical emergency. 

¹ Data rates may apply. 

² Virtual primary care is applied to primary care benefits—it is not applied to the 24/7 Virtual Visits benefit. 

³ Certain prescriptions may not be available, and other restrictions may apply. 

24/7 Virtual Visits is a service available with a provider via video, or audio-only where permitted under state law. It is not an insurance product or a health plan. Unless otherwise required, benefits are available only when services are delivered through a Designated Virtual Network Provider. 24/7 Virtual Visits are not intended to address emergency or life-threatening medical conditions and should not be used in those circumstances. Services may not be available at all times, or in all locations, or for all members. Check your benefit plan to determine if these services are available.