First, what
does the
term mean?
Let's first
get a
definition
of the term,
out-of-network:
This phrase
usually
refers to
physicians,
hospitals or
other health
care
providers
who are
considered
non participants
in an
insurance
plan
(usually an
HMO or PPO).
Depending on
an
individual's
California health
insurance
plan,
expenses
incurred by
services
provided by
out-of-plan
health
professionals
may not be
covered, or
covered only
in part by
an
individual's
insurance
company.
How does it
affect your
health
insurance
plans?
It partially
depends on
the type of
health
insurance
plan you
have.
For
HMO
plans,
out-of-network
takes on a
much more
serious
importance.
HMO's by
definition
are more
structured
in terms of
access to
the care.
You must
stay within
your chosen
medical
group and
primary care
physician
unless you
have a
true
emergency
situation.
There are NO
benefits for
out-of-network
providers
aside from a
true
emergency...and
be
conservative
about how
you view
emergency.
PPO plans
are more
where the
term "Out of
Network"
comes into
plan.
Essentially,
a PPO plan
is a network
of
"In-Network"
doctors,
hospitals,
and medical
providers
that have
contracted
with the
California
health
insurance
carrier to
provide
medical
services to PPO members
at a
discounted
(contracted)
rate.
This is the
negotiated
rate that we
reference
through the
website.
When you run
your health quote,
you will see
a benefit
summary for
the various PPO plans
(most HSA
plans use
the PPO
network).
This assumes
you use
in-network
providers
for covered
benefits.
With PPO,
you can use
providers
that are not
in the
network but
you will pay
more out of
pocket.
There are
two ways
this
happens.
First, the
benefits for
out-of-network
providers
are not as
rich as in
network.
For example,
in network
for labs
might be
80/20 (you
pay 20% and
the carrier
pays 80%)
but for out
of network,
it might be
50/50 (you
pay 50% now
instead of
20%).
Secondly,
the carrier
will usually
apply these
less rich
benefits to
what they
would pay an
in-network
provider.
For example
(continuing
with the
labs example
above), if
the
out-of-network
provider
would charge
$500 and the
in-network
charge is
$300
(discount is
usually
30-60%), the
provider
would pay
50% of the
$300 or
$150.
With an
in-network
provider,
the carrier
would pay
80% of the
$300.
The
difference
out of the
member's
pocket is
$60
(in-network)
versus $350
(out-of-network).
That's a big
difference
so it's
always
important to
stay within
network when
possible and
verify that
providers
are
in-network.
More
information
on the
networks in
California
Each
carrier's
networks
will be
different in
terms of the
doctors and
hospitals
that they
contract
with.
There is
also a
distinction
between
their HMO
and PPO
networks.
Usually, the
HMO network
is smaller
than the PPO
list of
providers.
A doctor may
participate
in either
one (HMO or
PPO) but not
the other so
always
verify that
your doctor
is available
with the
type of plan
you are
interested
in.
The
large health
carriers
typically
have PPO
providers in
almost all
California
counties and
areas.
HMO networks
are missing
from some
areas,
especially
less
populated
areas.
By
definition,
HMO's tend
to work
better is
larger
cities and
more
populated
areas.
Rural areas
do not work
well with
HMO areas.
EPO
(Exclusive
Provider
Organization)
is typically
the same
network as
the PPO list
but there
are no
benefits out
of network
with an EPO.
This can
also impact
a person's
ability to
use the
Blue Card
network
with
Anthem Blue Cross
or
Blue Shield
of
California.
Health
Savings
Accounts and
out of
network
There are
times when a
person's
preferred
doctor is
not
in-network
with their
carrier (or
any
carrier).
This can
mean that
they will
pay more for
using these
providers as
mentioned
above.
Health
Savings
Accounts
work well in
this
situation
because the
funds in the
HSA account
itself can
be used for
claims in or
out of
network.
The eligible
expenses go
according to
the federal
guidelines
and there is
no
distinction
between in
or out of
network.
In summary,
always try
to stay in
network.
Verify with
doctors,
labs, and
facilities
that they
are
in-network
before using
their
services.
This will
not only
keep your
out of
pocket
expenses
down but
will allow
you to take
advantage of
the greatest
benefit of
PPO
plans...the
negotiated
rates.
|
