The amount you pay for a service and how much HMSA pays are based on the eligible charge. The eligible charge is the lower of the participating provider’s actual charge and HMSA’s maximum allowable fee. HMSA contracts with participating providers to accept the eligible charge as payment in full for services covered by your plan.
Note: You’re responsible for the entire amount charged by your provider for services that aren’t a benefit of your plan.
If you have a PPO plan, see Why Your Cost may be More When You See a Nonparticipating Provider for more information on how the eligible charge applies to you.