An out-of-network provider is a provider that is not in contract with your insurance company for reimbursement at a negotiated rate. Health insurance plans like HMOs and EPOs do not reimburse out-of-network providers at all. The only exception is the emergency conditions otherwise; these plans do not reimburse your medical cost in case of out of network providers. You alone are responsible for the full amount charged by your doctor if your chosen doctor is not in your insurer’s network.
An in-network provider is a doctor or hospital who has signed a contract with the insurance company and has agreed to render health care services to the members of the plan at discounted rates. An out-of-network provider doesn’t signup any contract or agreement with your insurance company, so you are required to pay the full cost of your medical care. A doctor or a hospital may not be in your insurer’s network because the doctor or hospital might not consider your insurance company’s negotiated rates to be adequate, as this is the prime reason for insurers not to join any particular network.
Health insurers maintain network directories with a list of all the healthcare providers who are included in their network. The healthcare providers or hospitals included in the list are considered in-network providers and who are not on the list are considered out-of-network providers. However, you can also directly call the healthcare provider to find out whether they are in your plan network or not. You should know that a particular insurance company provides different types of coverage in a state, and the network of every plan varies. Employer-sponsored health plans might have a more extensive network than individual market plans. Therefore, a doctor or hospital may be included in a network of an insurance company, but might not be included in all of their plans.
Sometimes, there may be situations when you have to use an out-of-network provider, or you might have no option other than choosing a non-network healthcare provider. Find below some of the conditions during which you might need to opt for out-of-the-network coverage.
Medical Emergencies – Medical emergencies are situations when you may need closet medical help available. According to the Affordable Care Act, insurance companies are required to cover emergency medical care exactly as per in-network providers. Irrespective of whether emergency medical care is obtained at an in-network or out-of-network healthcare facility, insurers have to reimburse the healthcare costs.
Specialized Care – If you are suffering from a rare or peculiar ailment, and there no specialist doctor of that ailment included in your plan, then you might require out-of-network healthcare. In such circumstances, you have to receive specialized care from an out-of-network healthcare provider.
Your Health will be Jeopardized – If you are receiving treatment for any serious or end-of-life issues, and suddenly your doctor leaves the network. Then, you can continue receiving your care from the same doctor. You can request to consider your treatment as an in-network coverage. Especially if it is for a certain time or a set number of doctor’s visits.
Out-of-town care – There are chances when you might need medical care while being away from home, and you may have to go to out-of-network providers. Some of the insurance companies may consider your visit to a non-participation provider, like an in-network provider but not all insurance carriers will consider your out-of-network visits. Moreover, there are chances that in-network providers may be available, and so if it is not an emergency, you should first consult with your insurance carrier to find out if an in-network provider is available or not, and then accordingly plan your visit.
No-access to in-network provider – If you live in a rural area where there is no realistic access to an in-network provider in your place, then you may have to use a non-participating doctor, as visiting an in-network doctor might not be possible for you due to distance issue. So, you may be able to appeal to get coverage for an out-of-network provider in your area.