California Brokers – SBG/LG Amendment to EOCs – Maximum Allowable Amount Update
Effective September 15, 2016
Approximately 7,000 members will receive the following letter/amendment.
Maximum Allowable Amount is the amount on which Health Net bases its reimbursement for Covered Services and Supplies received from an Out-of-Network Provider, which may be less than the amount billed for those services and supplies. Health Net calculates Maximum Allowable Amount as the lesser of the amount billed by the Out-of-Network Provider or the amount determined as set forth herein. Maximum Allowable Amount is not the amount that Health Net pays for a Covered Service; the actual payment will be reduced by applicable Coinsurance, Copayments, Deductibles and other applicable amounts set forth in this Evidence of Coverage.