Affordable Insurance Products

CGHI Tools

Maximum Allowable Charge (MAC)

The MAC is central to all of HealthMarkets' Consumer Guided Health Plans. MAC represents the maximum amount the plan pays for any covered medical service. The MAC for each service is set locally so that many doctors and hospitals in a local area accept MAC as payment in full.

If you seek care from a provider who charges more than the MAC, you will simply be responsible for paying the difference or negotiating with the provider to accept the MAC. It's easy to see which providers charge below the MAC — what we refer to as "In the Green"* — by using the web site or by phoning customer service.

Thanks to MAC, you can use your plan benefits anywhere, even in an emergency while traveling outside the country. And with no network restrictions or out-of-network penalties, you are free to seek care from any provider — the choice is yours. Referrals are also never required.

* Selecting providers "In the Green" is not a guarantee that enrollees will stay within the MAC for a particular service. Providers change their charges from time to time. When charges exceed the MAC, enrollees will be responsible for the difference. To confirm that a provider's charges will be at or below the MAC, enrollees should speak with their provider before receiving services.

HealthMarkets SMARTFUNDSSM

HealthMarkets SMARTFUNDS empowers consumers to manage their care around certain medical conditions and procedures.

A SMARTFUNDS allowance is a specific maximum dollar limit that the plan sets for treatment of specific medical conditions — from diagnosis through office visits, surgery, hospitalization and follow-up care. Your SMARTFUNDS allowance can be thought of as a personal budget for treatment, providing a strong incentive to use health care services effectively and to spend wisely. If you exceed the SMARTFUNDS allowance, any additional costs are your responsibility.

With HealthMarkets SMARTFUNDS, we've identified more than 100 medical conditions and procedures you are likely to encounter — we call them SMARTFUNDS conditions. We selected conditions you would generally know about ahead of time so that you would have the opportunity to work with your doctor to plan your treatment. Examples of SMARTFUNDS conditions include an upper respiratory infection, knee surgery, pregnancy, hypertension, asthma, and gall bladder surgery.

SMARTFUNDS allowances are calculated from a base dollar amount that is then adjusted for a person's age, gender, the presence of other medical conditions and the cost of health care services where he or she lives. For example, a 60-year old woman with high blood pressure and thyroid disease having knee surgery would get a higher SMARTFUNDS allowance than a healthy 20-year old having knee surgery because her costs are expected to be higher.

HealthMarkets provides many tools and services to help our customers manage their SMARTFUNDS allowances. You also have access to web-based decision-making support tools and a full medical encyclopedia. In addition, you can talk to any one of our HealthMarkets SMARTFUNDS specialists — specially trained customer service representatives with expertise in SMARTFUNDS allowance management.