Health insurance Your Coverage Options

Out-of-network coverage harder to come by

Written by Diane Archer

If you’re shopping for health insurance in a state health exchange, you may be hard-pressed to find a plan that covers your out-of-network care. And, that could mean huge out-of-pocket costs for some people. A new Robert Wood Johnson Foundation report shows that in 2016 fewer people will have access to Preferred Provider Organizations (PPOs)–the plans that tend to offer out-of-network coverage.

Why should you consider out-of-network coverage?  Even if you’re healthy, you may need it. If you travel, live in a different location for a part of the year or have family who live in another location, out-of-network coverage helps ensure you can get the care you need wherever you are. Or, you may be diagnosed with a costly or complex condition for which you want to see a doctor who is out of network. Part of the cost of your doctors’ and hospital care will be covered, both in your community and in other parts of the country as well.

Moreover, you may end up using out-of-network doctors for reasons outside your control–the anesthesiologist or radiologist in your network hospital, for example, may be out of network. Out-of-network coverage should give you some protection if a non-network physician treats you while you are in hospital. Click here to learn about how to protect yourself against unexpected bills when you are in the hospital.

For people without good out-of-network coverage, costs can be off the charts. A new report from America’s Health Insurance Plans documents the excessive prices doctors and hospitals often charge for out-of-network care.  In New York City, you can spend a day in the emergency room to treat a dizzy spell and the bill can total over $10,000. But, if your care is in-network, the hospital’s negotiated rate with your insurer could be $900, 90 percent less.

Today, there’s no limit on the amount hospitals and doctors can charge for out-of-network care. In most states, they do not even have to disclose their rates.  So, if you do get out-of-network coverage, find out what percentage of the cost your health plan will pay for and whether there is a limit on your out-of-pocket costs for out-of-network care.

In 2014, only about 35 percent of health insurance exchange plans were PPOs offering out-of-network coverage.  In 2016. people in 37 states will have far fewer PPO choices. Washington D.C., New York and New Jersey offer no PPO options in their state health insurance exchanges.

If you’re eligible for Medicare, keep in mind that traditional Medicare affords you the most comprehensive coverage, since you have very low or no out-of-pocket costs no matter which doctors you see or hospitals you use anywhere in the country, so long as you have supplemental insurance.


1 Comment

  • Something needs to be done to bring the medical costs down. It’s obvious that the big providers and the drug companies cannot police themselves. And the insurance companies are only interested in justifying rate increases.

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