The Hemet Teachers Association, an affiliate of CTA and NEA, is the exclusive representative of the teachers, counselors, nurses, psychologists and support services personnel of HUSD.

Self-Funded/Foundation Participants
OUT OF NETWORK CLAIMS
By Mike Reilly, HTA Insurance Consultant

Please be reminded of the following when choosing an Out of Network Provider.

If you choose to access care with a Non-Contracted provider-The provider must obtain a “Pre-Authorization” from SHPS before services can be rendered.  SHPS can be reached by calling 888-668-2273.  

If NO authorization is obtained the following penalties apply.

A 50% reduction in the Foundation Allowable Fee paid to the provider.

Example:

Billed Amount: $10,000.00

Foundation Allowable Fee: $4,000.00

Plan Pays (50% penalty for no Auth): $2,000.00

Members Responsibility: $8,000.00

The member will be responsible for the difference between the amount billed and the amount paid by the Foundation.

The balance due by the members does not apply towards the Out of Pocket Maximums.

If a non contracting provider renders service to you after obtaining an authorization the following example shows what your monetary responsibility would be.

Example: 

Billed Amount: $10,000.00

Foundation Allowable Fee: $4,000.00

Plan Pay 80% of Contracted Rate : $3,200.00

Members Responsibility: $6,800.00

Selecting a non network provider creates a greater out of pocket expense for you the member. 

The member will be responsible for the difference between the amount billed and the amount paid by the Plan. 

The balance due by the member does not apply towards the Out of Pocket Maximums. 

Please verify with your provider that they have obtained authorization from SHPS prior to having services rendered, in order to limit your out of pocket expense.

Please Note: This provision does not apply when services are rendered by a Participating Provider, in a Participating Hospital, and a non participating provider is used for additional services ie. anesthesiologist, lab etc.

If you need clarification on these benefits please contact the Foundation at 951-686-9049 or 800-458-5710.