In-Network and Out-of-Network Care
Your plan contracts with a wide range of doctors and other practitioners, as well as hospitals, labs, radiology facilities, pharmacies and other providers. These are the providers in your “network.” Each of these providers has agreed to take your plan’s contracted rate as payment in full for services.
That contracted rate includes both your insurer’s share of the cost, and your share. Your share may be in the form of a copay, deductible or coinsurance (see cost sharing).
If you go outside your network, you will likely pay more for your care. That’s partly because providers outside your network have not agreed to any set rate with your insurer. Those providers may charge more. Another reason is that your plan may require higher copays, deductibles and coinsurance for out-of-network care. Or, they may not cover out-of-network care at all, leaving you to pay the full cost.
There are reasons why you might go out of network. If you or a loved one is facing a serious sickness, you may want more choices than you can get in your network. Or, you might go out of network by accident. That can happen if you get care from an out-of-network doc at an in-network facility.
Follow these tips to help handle your costs:
- Ask your primary care provider (PCP) to refer you to a provider in your plan’s network.
- Before scheduling a visit with a new provider, ask if he or she accepts your plan and is willing to see new patients.
- Will you be having a complex procedure, like a surgery? If so, ask your doctor whether all of the providers who will join in your care are in your network.
- Suppose you choose to go out of network. If so, ask the provider’s staff before your visit how much he or she will charge. Then, talk to your insurer to find out how much of the cost your plan will cover.
- Is the out-of-network provider’s charge higher than your insurer’s allowed amount? If so, check the FH Consumer Cost Lookup to see what providers in your area usually charge.
Know Before You Go
You’ve probably seen the terms “in-network” and “out-of-network” on your insurer’s website and in your plan description. But, what do these terms mean? And how do they affect how much you have to pay for your care?
|HMO In-Network||POS In-Network||EPO In-Network||PPO In-Network|
|Provider’s Usual Charge||$1,000||$1,000||$1,000||$1,000|
|Your Plan's Contracted Rate||$500||$500||$500||$500|
|Your Cost Sharing||$10 copay||$10 copay||20% coinsurance||20% coinsurance|
|Your Plan pays||$500 - $10 = $490||$500 - $10 = $490||$500 x 80% = $400||$500 x 80% = $400|
|You pay||$10 (1%)||$10 (1%)||$500 x 20% = $100 (10%)||$500 x 20% = $100 (10%)|
|HMO Out-of-Network||POS Out-of-Network||EPO Out-of-Network||PPO Out-of-Network|
|Your Plan's Allowed Amount||$0||$800||$0||$800|
|Your Cost Sharing||100%||30% of the allowed amount PLUS the difference between the allowed amount and provider’s charge||100%||30% of the allowed amount PLUS the difference between the allowed amount and provider’s charge|
|Your Plan pays||$0||70% of $800 = $560||$0||70% of $800 = $560|
|You Pay||$1,000 (100%)||30% of $800 = $240 PLUS $1,000 - $800 = $200||$1,000 (100%)||30% of $800 = $240 PLUS $1,000 - $800 = $200|
|Your Total Cost||$1,000 (100%)||$440 (44%)||$1,000 (100%)||$440 (44%)|