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Tips on Insurance Policies for Out of Network Care

Here’s a situation: you are visiting your family who live in another state. You are taken ill during your visit—while not an emergency, you cannot wait to see a doctor till you get back home. If you visit a local clinic or hospital, there is a 50% chance that they are a part of your health plan’s network. But what if they are not? This article will help you understand the difference between an in-network and out-of-network provider and also walk you through steps you can take to have your out-of-network charges covered by insurance.

Difference Between In-network and Out-of-network Care:

  • In-network or participating provider: a doctor or health care service provider who accepts your insurance plan
  • Out-of-network (OON) provider: a doctor or health care service provider who does not accept your insurance plan
  • PPO (Preferred Provider Organization) plan: Includes OON benefits, but the patient’s share in cost may be more.
  • HMO (Health Maintenance Organization) plan: These plans do not include OON benefits, so patient has to cover the entire cost for an OON provider.

Under What Scenarios Would Someone Use an OON Provider?

  • In an emergency situation, where urgent care is needed
  • If you or a family member suffer from a rare disease
  • If none of the in-network providers have the experience or expertise needed to care for you
  • Accidentally, e.g., you could get the services of an OON doctor who may be working at an in-network hospital

Here’s an article that explains how the No Surprises Act is trying to protect consumers in such situations.

What Happens When You Use the Service of an OON Provider?

  • You may have to pay more for the care received, because the OON provider does not have an agreed-upon payment rate with your health insurance plan
  • Your plan may increase your cost-sharing—a higher copay, deductible, and coinsurance for OON care
  • You may be responsible for the full cost of the care received if your health plan refuses to cover OON care

Can I Get In-network Rates for an OON Service? How?

  • Make a formal request/appeal to your health plan
    • This may be done by your primary care provider or in-network specialist 
  • Send a request for prior authorization to your health plan
    • This may be done by your primary care provider or in-network specialist 
  • If your request is denied:
    • You may ask for an internal review by the insurer
    • If that is denied, then depending on your state’s laws, you can initiate an external appeal, meaning appeal to an independent group

Special Situations Where You May Receive In-network Rates for an OON Service 

  • Emergencies, where you may need care right away, even if the ER is not within your network
  • You live in a geographically remote area with limited access to experts
  • You need an expert for a specific rare condition
  • If your current in-network doctor, treating a serious condition:
    • leaves your health plan’s network 
    • is not a part of the new health plan, if you change your health insurance
  • If you are required to evacuate in case of a natural disaster, and the state has declared an emergency
    • For children who move away to college and need to visit a local doctor

Check the laws in your state of residence on in-network rates for OON services. It’s always advisable to speak with your health insurer about their policies.  

Resources

Here are some detailed resources on understanding OON costs:


Surabhi Dangi Garamella

Surabhi Dangi-Garimella, Ph.D. is a biologist with academic research experience, who brings her skills and knowledge to the health care communications world. She provides writing and strategic support to non-profit groups via her consultancy, SDG AdvoHealth, LLC.

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