Out-of-network care

The second question in the survey asked consumers whether their health plan would pay any of the costs if they went to an out-of -network doctor without a referral. Almost 70% of the consumers surveyed answered this question correctly.

Point-of Service plans and Preferred Provider Plans are managed care plans that allow individuals to choose any provider for most covered services. However, you generally must pay higher deductibles and co-insurance amounts for services from out-of-network providers.

If you are covered by a health plan that provides out-of network coverage, it is important to review all of your plan materials so that you understand any restrictions that may apply. There may be some benefits that are only available from network providers. For example, many preferred provider plans will only pay for routine physical examinations and other preventive services if a network doctor provides them.

It is also important to be aware of the additional cost you may have to pay if you choose an out-of-network provider; this can be a substantial amount. Find out if there is an additional deductible amount, and how much additional co-insurance you must pay. Many health plans require you to pay an additional 20-30% of the provider's charges if you see an out-of-network provider. If you are having an expensive procedure, this can be a large amount of money. You may also have to pay an additional amount if the out-of-network provider charges more than a "usual, customary, and reasonable amount." This is based on the amount all health care providers in your geographic area charge for a specific service. If your out-of-network provider charges more than this amount, you will be responsible for paying the difference. The agreements between your health plan and network provider generally requires the network provider to accept the health plan's allowed amount and only bill you for any deductibles or co-insurance amounts.