Considering Your Healthcare Costs: In-Network vs. Out-of-Network

When working with a health insurance broker, you may have questions about your network coverage when viewing potential PPO plans. In short, any care you receive in-network will be considerably cheaper than the care you receive out-of-network. Out-of-network physicians and healthcare facilities can be utilized, but it may be a wiser decision to consider your in-network options first.

 
In-Network vs. Out-of-Network

In-network healthcare providers have a contract with your insurance company to provide plan members with lower-cost medical treatment. These providers often consist of:

• Hospitals
• Doctors
• Pharmacies
• Dentists
• Other medical specialists

 
The contract between the provider and insurance company requires the provider to offer care at an agreed-upon rate. On the other hand, out-of-network providers do not have any type of agreement with your insurance company. These providers may accept other insurance plans or they may not accept insurance at all. Your insurance company will typically provide some coverage for such providers, but it will not be as extensive as the coverage provided to in-network providers. This means it will cost you more to see an out-of-network provider, even with insurance.

 
How Much is Out-of-Network Care?

One of the reasons out-of-network care is significantly more expensive is because there are no cost-sharing functions. These functions are as follows:

• Deductibles – The amount of money you must pay before your health insurance coverage becomes active.
• Coinsurance – The percentage of medical costs you must pay after receiving care or treatment.
• Copay – An amount charged for medical care and prescription drugs. 

Deductibles, coinsurance, and copays only apply to providers who are in-network. If you receive care from a physician outside of your network, you will be responsible for paying a higher percentage of your medical costs. The amount of out-of-network coverage you have will depend on the insurance plan you choose. More expensive plans typically provide more coverage for out-of-network providers.

As mentioned above, the amount your health insurance company will pay an out-of-network provider will depend on the plan you choose. However, regardless of the plan you select, you will typically be charged a “reasonable and customary” amount for the medical care you receive out of network. For example, if you go to an out of network primary care physician, and you are charged $200 for an appointment, your health insurance company may only cover $100 for your visit. Conversely, if you go to an in-network primary care physician, you may only be responsible for a small copay.

Is Your Provider In-Network?

To find out if a provider is in-network or out-of-network, you may be able to visit your insurance company’s website. The provider or facility’s website may also state if they take your insurance plan. Checking online is one of the easiest options, but you may not always be able to find the information you need there. If you do not know whether a provider takes your plan, you can always call the provider directly or talk to a representative from your insurance company.

 
Find Out More

A qualified health insurance broker can help you find and select a plan that meets or exceeds your particular needs. By working with a broker, you can find a plan with an in-network provider you can trust. Contact Sackett & Associates Insurance Services today at 707-823-3689 to find out more.