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Non-network Services


Non-Network Services and Payment

If you're a member of an HMO, paying for out-of-network treatment is pretty straightforward: You pay for it all yourself. PPOs can get a bit more complicated. Typically, because PPOs are a bit more expensive than HMOs, you'll get some coverage when you go outside the network. Providing that you are receiving eligible services, and that your insurer has preapproved the treatment (if necessary), a percentage of your bill will be paid. For example, your insurer will pay for a visit to an in-network doctor for a simple problem, and you will be expected to pay a simple co-payment. However, a visit to the same sort of doctor, out of network, may be covered only 80 percent, so you'll have to fork out the remaining 20 percent in addition to your co-pay. This is known as coinsurance. This is true even if an in-network doctor referred you to the out-of-network provider. As we mentioned, your doctor should refer you to an in-network specialist. But if for some reason he or she sends you out-of-network, you should do some research and check if there is an in-network specialist.

Payment Methods
Obviously, if you're in a managed health care plan, you're going to avoid seeking treatment outside your network. But hypothetically, (assuming you've already met your annual deductible) the cost breakdown might go something like this: 

 In Network

 Out of Network

Provider bill

 $150

 $150

What insurers are allowed to charge 

 $100

 $100

Provider discount

 $50

 $0

What insurer pays 

 $90

 $60

What you pay

 $10

 $90

Fortunately, though, many managed health care providers are aware of how out-of-reach these costs can be for their customers. Some have found ways to deflect them by negotiating with the provider for you or setting up a fee schedule (payment plan). But if these measures are available, they usually have to be arranged in advance. Managed health care plans do everything they can to keep you within the network -- they don't go as far as forbidding you to seek care elsewhere, but financially speaking, it works out to be a kind of de facto prohibition.

For more information about non-network services, check out the links on the next page.