What is Out-of-Network Coverage?

Out-of-network coverage is a term that refers to medical providers, facilities, and treatment options outside your health insurance company's group of affiliated doctors. This article will cover out-of-network coverage and how healthcare plans' networks work.

Out-of-network coverage is a type of health insurance plan that covers doctors and other healthcare providers not in your insurance company’s network. This coverage can be helpful for people with specialized medical needs, traveling or living in areas with high medical costs, or wanting to maximize their choices regarding medical care. In general, out-of-network coverage is a bit more expensive than in-network coverage. The insurance company may not pay as much for out-of-network care. This is why it’s important to understand how your insurance plans work when it comes to in-network and out-of-network medical care. Many health insurance companies have a network of affiliated doctors, facilities, and other treatment options they will pay for at negotiated rates. Those not in your insurance company’s health network are considered out of network and will be responsible for paying the full cost of their care.

The Most Common Out-Of-Network Health Coverage Situations
What is Out-of-Network Coverage? 1

The Most Common Out-Of-Network Health Coverage Situations

The most common type of out-of-network care involves a visit to a physician or other healthcare provider. This can happen for a variety of reasons, including when your preferred provider leaves your health insurance plan’s network or you move to a new area where there is no provider network available in your new location.

Another common reason why people end up paying out-of-network for healthcare is during an emergency. Getting emergency medical care from an out-of-network doctor can be extremely costly, and knowing how your health insurance will cover this type of medical care is important before you need it.

Sometimes, when you get care from an out-of-network provider, your health insurance may pay for a portion of the service, such as your copayment or coinsurance. These amounts differ from plan to plan, and some use UCR charges or Medicare fee schedules to calculate what they’ll pay.

The No Surprises Act bans out-of-network balance billing for emergency services, including hospital or urgent care visits, and most non-emergency medical services (like anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, and intensivist services). Any out-of-network payments for these services count toward your deductible and out-of-pocket maximum.

How to Avoid Unexpected Insurance Bills
What is Out-of-Network Coverage? 2

How to Avoid Unexpected Insurance Bills?

If you use an out-of-network doctor or facility, it’s also important to research the quality of your provider. This includes looking up their credentials and background, such as licenses, board certifications, medical school, and residencies. This can help you choose a quality healthcare provider knowledgeable about your particular condition and how to treat it. It can also help you avoid any unexpected out-of-network costs and stay within your budget.

Your health insurance plan will usually have a network directory that shows you which doctors, hospitals, and other providers are in your network. The directory will also tell you if your plan does not cover an out-of-network provider. If you’re unsure about your coverage, asking your health insurance agent is always a good idea. They can also provide an easy-to-understand notice explaining why getting care out of network might be more expensive and your options for avoiding balance bills.

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