Going Out-of-Network for Medical Care

Individual and Family

Going Out-of-Network for Medical Care

Published on July 24, 2018


Many common health insurance plans nowadays have “networks”. Making sure you know what’s included in your network is incredibly important when choosing your health insurance plan.

What is your network?

To understand the consequences of getting out-of-network care, you first need to know what your network is. A healthcare network is a group of care providers, suppliers, hospitals, and clinics that have agreed to offer health care services at a discounted cost and your insurer has approved for reimbursement. Typically, these organizations and professionals need to meet certain criteria that your insurer sets for care quality and affordability. By limiting acceptable providers based on these criteria, your insurer can reduce risk and keep costs under control; they then pass these benefits on to you in the form of lower premiums and more comprehensive coverage.
Health care networks are not set in stone. If a provider doesn’t continue to meet your insurer’s requirements, or if your insurer tightens those requirements and your provider doesn’t keep up, that provider might be removed from your network. Likewise, your insurer may choose to cover different kinds of care than they did before, and will have to update the network accordingly. For example, if your insurer changes your current plan to include psychological care, they will need to expand their network to include psychologists, behavior medications, and other professionals and resources related to that care.

While eHealth does have plenty of useful tools to help you find out who’s in your network, or which networks a certain health care provider is in, these tools might not always reflect the most recent network updates. Each insurance plan periodically updates its list of in-network doctors and providers, so always double check coverage with both the plan and the doctor or provider before choosing a plan or incurring medical expenses.

What happens when I go out-of-network?

The consequences of receiving out-of-network care vary based on the specific policies of your health insurer. Different types of health insurance plans have different rules about out-of-network care; the most common types include:

  • HMOs– Short for health maintenance organizations, HMOs tend to have the strictest policies on out-of-network care. These plans typically do not pay for any care that you get out of your network, unless that care addresses a true emergency or meets some other specific qualification.
  • PPOs– Preferred provider organizations, or PPOs, are more flexible on out-of-network care. They pay for at least part of the cost for care you get from qualified providers who are out-of-network, though they typically do not cover as much as they would for in-network care.
  • Other Plans– Other types of plans include Provider Sponsored Associations, or PSOs; Private Fee for Service plans, or PFFS; and Medicare Medical Savings Accounts, or MSAs. If you have any of these plans, you should check the specific policy on paying for out-of-network care.

Even if your plan offers the highest degree of coverage for providers outside your network, you may still have to pay more. For example, it may be that your insurance will pay $400 for a given procedure, which is what providers in your network charge for it, but a provider outside your network charges $600. This means that if you get care from that provider, you’ll have to pay at least $200.
Watch the below video in order to get an overview of costs associated with going out-of-network:

Why might I seek care outside my network?
While staying in your network is generally advisable, there are certain situations where you may need to leave it, including if:

  • You have a health emergency and need care from the closest provider; by law, your insurance has to cover this care, though you may still need to go through a lengthy reimbursement process
  • You need the aid of a specialist who isn’t in your network
  • Your current care provider drops out of the network and it wouldn’t be good for your health to switch to another provider
  • You need care while out of town and your network doesn’t extend to that location

For more information on whether to go out-of-network and other tips to make the most of your health insurance, contact eHealth today.

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