Insurance Plans Accepted

Managed Care Contracts

In an effort to better serve our patients and physicians, Southwest General has pursued contracts with many Managed Care Organizations (MCOs). We strive to develop contracts with companies who not only provide good medical coverage to their subscribers, but also who provide fair reimbursement and equitable contract terms. In addition to accepting traditional Medicare and Medicaid, Southwest has arranged special “managed care” contracts with the following entities:

Southwest General accepts all Medicare Private Fee For Service (PFFS) plans.

This list is meant to be a basic guide and not provide detailed information. Periodic updates to this list may occur. If you have any questions or require additional information please contact Michelle at 440-816-6779

Aetna Commercial
Please see non-contracted list for exceptions

• All Aetna Commercial plans*
• Aetna Meritain
• Individual Exchange
• GEHA

Aetna Medicare Advantage
Please see non-contracted list for exceptions

• All Aetna Medicare Advantage plans*

Aetna Other Government

• Aetna Medicare HMO Dual SNP (DSNP)

AmeriHealth Caritas - Medicaid

Anthem BCBS Commercial
Please see non-contracted list for exceptions

• All Anthem BCSC Commercial plans*
• Traditional, Blue Access
• Blue Access (OH I &II)
• Pathway, Pathway X

Anthem Medicare Advantage
Please see non-contracted list for exceptions

• All Anthem Medicare Advantage plans*

Anthem Medicaid

Beech Street - PPO

Behavioral Health Systems

• Behavioral Health Only

Buckeye Community Plan

• Medicaid
• AllWell Medicare Advantage
• Ambetter (Exchange HMO)
• MyCare Ohio

CareSource

• Medicare Advantage
• Medicaid
• MyCare Ohio, D-SNP
• Marketplace (Exchange) Hospital only

Carelon Behavioral Health (Beacon Health) (Value Options)

• Behavioral Health Only

Cigna Evernorth Behavioral Health

• Behavioral Health Only

Cigna Healthcare
Please see non-contracted list for exceptions

• All Cigna Commercial plans

Cigna Medicare Advantage

ClaimDoc

Clarity Health

Communicare Medicare I-SNP

Devoted Health Medicare

• Medicare Advantage

First Health/CCN/Coventry PPO

HealthSmart PPO

Health Ohio Network PPO

Healthstar PPO/PPO Next

Horizon Health- Behavioral Health Only

Humana
SWG and SGMG are Out of Network with Humana Medicare Advantage. Please see non-contracted list for exceptions*

Humana Health Horizons

• Medicaid

Humana Behavioral Health

Medical Mutual of Ohio
Please see non-contracted list for exceptions

• All MMO Commercial plans*
• MMO Exchange NE Ohio HMO

MMO Medicare Advantage

Molina

• Medicaid
• Marketplace Exchange

Northcoast HealthCare

• Home Health

Ohio Bureau of Workers' Comp

• All BWC MCO's

Ohio Health Choice/OHC Plus

Paramount Elite Medicare - SGMG only

PHS/Direct Care America - PPO

PHCS/MultiPlan - PPO & POS

SummaCare
Please see non-contracted list for exceptions

• Commercial
• Medicare Advantage

TheraMatrix Physical Therapy Network

TriCare: Humana TriCare

• Prior auth may be required

United Behavioral Health (Optum)

• Behavioral Health Only

United Healthcare Commercial
Please see non-contracted list for exceptions

• All United Healthcare Commercial
• GEHA / UMR
• UHC Nexus ACO - TIER 2

United Healthcare Medicare Advantage

• United Healthcare GEHA Medicare ADV
• UHC MyCare Ohio (UHC Connected Care)
• UHC Dual Complete – HMO SNP

United Healthcare Medicaid

• UHC Community Plan

Veterans (VA)

• Please note – Providers may need approved referral from the VA prior to rendering care

Wellcare Medicare Advantage

Non-Contracted Insurance Plans

Non-Contracted or “Out-of-network” (OON) means providers and facilities that haven’t signed a contract with a health plan to provide services. Out-of-network providers may be allowed to bill for the difference between what the plan pays and the full amount charged for a service. This is called “balance billing.” “Surprise billing” is an unexpected balance bill. Surprise medical bills could cost thousands of dollars depending on the procedure or service.

All SWG Patients are protected under the No Surprise Billing Act (NSA) that went into effect 1/1/22. In short, patients will be billed no more than their in-network patient out-of-pocket amounts according to their benefit plans. Any and all additional reimbursement must come from the payer’s OON payment rate OR a further negotiated single case agreement. Southwest General DOES NOT BALANCE BILL patients and will work with all plans to be compliant with the NSA regulations. More information about the NSA can be found on our website under Financial Tools. If you have questions about an OON provider, please call or email Managed Care.

*Please note - this is not a complete list of non-contracted insurance plans, these are the most common plans.

Common OON Plans (should be registered under the correct I Plan)

Aetna

• Aetna Premier Care Network PLUS – exclusive to Cleveland Clinic
• Aetna Whole Health – Cleveland Clinic network
• MetroHealth Network

Anthem Pathway HMO X - exclusive to MetroHealth

Anthem Medicare Advantage

• Anthem MediBlue Prime Select (HMO) – exclusive to Cleveland Clinic
• Anthem High Performance Network—exclusive to Cleveland Clinic

CIGNA Open Access Plus Pathwell Pharmacy Benefit

Humana Medicare Advantage including Humana HMO D-SNP

• See SWG website
  https://www.swgeneral.com/financial-tools/medicare-advantage-update/
• Humana Cleveland Clinic Preferred (HMO) & Humana Cleveland Clinic (HMO SNP-DE) – both plans are exclusive to Cleveland Clinic

Medical Mutual

• Mercy Health, MetroHealth, CLE-Care HMO, Skycare, Ohio Health HMO, Promedica HMO, Dayton HMO

Molina

• Molina Dual Options MyCare Ohio
• Medicare Complete HMO D-SNP

Oscar health plans

• Includes Cleveland Clinic plan

Paramount Elite Medicare Advantage - Hospital

SummaCare

• New Health Connect – Summa & Mercy Canton/CCF employee health plans
• SC Connect – Marketplace plan (offered in Summit, Stark, Portage & Medina Counties)

United Healthcare Exchange

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Other Non Contracted/ OON “Plans” not subject to NSA:

Reference Based Plans-- These plans typically have NO NETWORK even possible and have “Acceptance Language” on the card that says we would accept a low percentage of Medicare (e.g. 120% of Medicare) for the services. These are not recognized by SWG as Contracted Plans and therefore do not accept or recognize a discount, unless the medical plan can access a contracted wrap PPO network (common examples: Cigna, PHCS, or First Health).

Example Referenced Based Pricing Plans (not complete, just some common ones)

• Lucent Health
• CommuniCare Health Benefits (not the CommuniCare SNFs in our area)
• The Health Plan
• ClearChain
• Sana
• Sidecar Health –should register as selfpay

Healthshare Programs- Healthshare Programs are NOT insurance. They are predatory and profit seeking companies that more and more patients are presenting with. They may or MAY NOT pay anything towards the patient’s bill.

Patients who present with only a Healthshare card should be registered with the HEALTHSHARE insurance plan. If you are unsure if it’s a healthshare program, you can register it under MISC COMMERCIAL INS.

Example Healthcare Sharing Plans -

• MediShare
• Harmony Healthshare
• Liberty Healthshare
• Christian Healthshare Ministries (CHM)

*Please note this is not a complete list of non-contracted insurance plans, these are the most common plans.