Your health insurance plan has a network of healthcare providers who have signed contracts with your insurance carrier to provide members with services at negotiated prices. Depending on the type of plan you are enrolled in, your coverage may only allow you to see in-network providers. EPOs and HMOs heavily restrict their out of network coverage, if they cover it at all. PPOs and POSs will allow you to see out of network doctors, though there may be some limitations such as requiring prior approval.
How does a plan network work?
When you stay in-network, you are able to take advantage of the insurance carrier’s negotiated rates for services that are subject to deductible and coinsurance, and you may even have set copays for some services that you receive. No doctor will be able to charge you more than what your and their contract with the insurance carrier allows. This can help you keep the cost of your medical care down.
NOTE: If you need to visit an emergency room, you can visit the nearest hospital with no concern for whether or not it’s in your plan’s network. Medically-necessary emergency room visits are always covered as in-network, even if you’re overseas.
If I go out of network, how does my coverage work?
If you have a PPO or POS plan and go out of network to receive care, the amount that you will have to pay for your care can differ from the amount that you pay when you see an in-network provider.
When you go out-of-network, usually everything is subject to the deductible- even services that are covered with a copay or at no cost when you’re in-network. The deductible for out-of-network services is also separate from the in-network deductible and usually twice as high. Right off the bat, this can make your out-of-pocket costs balloon. The doctor is also allowed to bill you for the difference between what the insurance company’s contract rate is and what the doctor’s actual charges are. This practice is called “balance billing,” and is only allowed when you visit an out-of-network provider. Altogether, this makes your bill when you go out of network much higher than it would be if you stay in-network. You will also typically have to pay the full amount out of your pocket and file a claim for reimbursement with the insurance company, rather than having the doctor handle that portion.
How can I make sure that I’m staying in the network for my plan?
Every insurance company provides search tools so that you can make sure you’ll have coverage for your visits. We recommend that you use these prior to visiting a new doctor so that you can make sure that the doctor is in-network.
You can find the link to your provider's search tool in this article:
In-Network Doctor Search Tools by Insurance Carrier
I need to file a claim for out-of-network care that I received. How can I do that?
View this article to find detailed information about how to submit a claim through SimplyInsured
How do I file a claim through SimplyInsured?
If you have any questions about this, please submit a request to our customer care team at the link below: