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what to know before getting out of network care

If the doctor, hospital or health care facility you visit is part of your insurance company’s network, you’ll get your health care at lower prices. But if you go out of your network for health care, it can become a lot more expensive.

If you have an HMO or EPO plan, you’ll usually pay all costs for care you get outside of your plan’s network. So it’s important to carefully consider which doctors and hospitals are in a plan’s network before you buy it.

Here’s an example of how in-network and out-of-network benefits compare in PPO plans.

In-network: You go to a doctor and the total charge is $250. You get a discount of $75 because you went to an in-network doctor and our negotiated rate with them is lower. We pay $140. You pay what’s left, which is $35.
Out-of-network: You go to a doctor and the total charge is $250. You won’t get a discount because the doctor is out-of-network. We still pay $140, but you’ll be responsible for what’s left, which is $110. We call this balance billing.
Going out-of-network could mean you’ll have to pay a larger percentage of the cost or the total cost, depending on your particular plan. You may also pay a higher coinsurance percentage and have higher annual coinsurance and out-of-pocket maximums.