What Happens When You Need to Go to an Out-of-Network Provider with Your Private Health Insurance Plan?

Out-of-network providers are those doctors, hospitals, and other healthcare providers that do not participate in a specific California health insurance network. Generally, plans are not required to cover the care they receive from a provider that is not in the network, although there are some exceptions. Your share of the cost (also known as cost-sharing) is the deductible, copay, or coinsurance you have to pay for a given service. When you go off the grid, your share of the cost is usually higher.

The amount you have to pay depends on the type of health insurance you have. Even if every state had addressed surprise balance billing, most people with employer-sponsored health insurance still wouldn't have been protected against surprise balance billing. On the other hand, an out-of-network provider doesn't take into account what their health insurance company thinks. On average, the coinsurance rates paid by health insurance companies cover 75 to 90% of health care costs, leaving you to pay the rest.

It's important to understand how health insurance works, including possible out-of-pocket costs and the differences between different types of health plans. A Preferred Provider Organization (PPO) plan is a network of doctors, hospitals, and in-network medical providers who have a contract with the California health insurance company to provide medical services to PPO members at a reduced (contracted) rate. Additionally, no matter how serious the incident that caused your dispute was, your health insurance company won't advocate for you with an out-of-network provider that you can't influence. The maximum disbursement amount on your health insurance policy is designed to protect you from unlimited medical expenses.

When your health insurance company accepts a doctor, clinic, hospital, or other type of healthcare provider into its provider network, it negotiates discounted rates for that provider's services. If you have health insurance and get care from an out-of-network provider or at an out-of-network facility, your health plan may not cover the full cost outside of the network. For several years now, states have been taking steps to protect consumers from unexpected bills, but states cannot regulate self-insured health plans which offer insurance to most covered workers in very large companies. If you get health coverage in the health insurance marketplace or buy a health plan from an insurance company, new rules protect you from things like unexpected medical bills and confusing billing practices.

When you use a network provider for covered health plan services, that provider has agreed not to bill you for anything other than the deductible, copay, and coinsurance that your health plan has negotiated.

Tommy Gair
Tommy Gair

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