Important Questions and Answers Concerning Health Insurance in the United States.
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To help you save money, most health plans provide access to a network of doctors, facilities, and pharmacies. These physicians and facilities must meet certain credentialing requirements and agree to accept a discounted rate for services covered under the health plan; in this way a health professional becomes part of the network.
If a doctor or health center does not have a contract with your health insurance , it is considered out of network and you may be charged the full price of the consultation . The price you pay with an out-of-network doctor is often much higher than the in-network discounted rate.
Why Does Out-of-Network Care Cost More Money?
You’re probably paying full price . When health insurers don’t have a direct relationship with out-of-network doctors and facilities, they can’t control what is charged for services. And rates may be higher than the in-network discounted rate .
You may have to pay the difference . If your doctor’s bill is higher than what your plan will pay, you may have to pay that difference. Many health plans list an amount (which is the most) they will pay for a certain service received out-of-network . If the doctor or health center charges more than your plan is willing to pay, you are responsible for paying the difference in addition to the deductible, co-payment and/or coinsurance.
Some of the costs are different and usually higher . A co-payment is the amount you pay for covered health services at the time you receive the care. There are no copays when you use a doctor or facility that is out of network. Therefore, you will be the only person responsible for paying the coinsurance or a percentage of the covered charges.
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In-Network Costs vs. Out-of-Network Prices
Out-of-network costs can add up quickly, even for routine care. So if you have a serious illness or injury, it can mean paying thousands of dollars more out of pocket. Below, we show you a clear example of the charges of doctors (with average prices) for a general surgery:
Provider Networks in the US Health Insurance Market
When you choose a plan, you will usually have access to a specific provider network . Some networks may be larger than others or may include different provider options in your local area. It’s important to understand these differences when choosing a plan that meets your needs as a customer. Also, when you choose a plan, make sure that your provider is part of the network associated with the health insurance you are contracting.
Plans can vary, but in general, to save money, you should visit providers in the network that your insurance belongs to. Also, if your plan includes out-of-network benefits , eligible expenses are covered, but your costs may be higher. Depending on the plan you choose and where you live, network availability may vary.
It will always be important that you consult your health insurance documents to obtain details of the network to which you belong. Remember, when you’ve decided which plan you’d like to purchase, you can visit the provider directory to see if your favorite doctors or clinics are in-network.
Selection of a Primary Care Provider (PCP) in Health Plans
If you are purchasing Individual and Family Plan coverage through a state or federal marketplace, in most cases, you will be assigned a primary care provider . You can change your PCP after your planned start date.
If you enroll in a health plan through your employer (boss), check the company’s plan details to see if you must choose a PCP or if choosing a PCP is optional. Also, it never hurts to know if there are network requirements for your plan.
Physician Orders and PCPs
Depending on your plan, insurance may require a doctor’s order from your PCP to see a specialist. Referrals to OB/GYNs are not required for covered OB/GYN services in all plans.
Coverage outside the Service Area
Depending on your plan, benefits may or may not include out-of-network coverage. Check your health policy documents for important coverage information. Outside the United States, coverage is limited to emergency services as defined in the insurance documents.
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On the other hand, if you receive coverage through your employer, the company may offer coverage for health care services received outside the country when you travel for work. However, this is not the case in all cases and it is best to contact the company directly and verify the details of your coverage .
See a PCP when you’re on the go
Benefits may or may not include access to in-network and out-of-network health coverage while traveling. Coverage and reimbursement of medical bills (if necessary) vary by plan. In this case, it is best to consult directly with the insurer and verify the details of the policy.
On the other hand, you can investigate the provider directory of your health insurance to find those doctors that are available abroad and that are part of the network to which your health plan is associated. Lastly, remember that emergency services are always covered.
Should I Report Changes if I am part of the US Health Insurance Market?
As we mentioned earlier, each year the Health Insurance Marketplace has an open enrollment period and special enrollment periods for eligible taxpayers. For information about the next enrollment period , you should visit the HealthCare website and contact the state marketplace that corresponds to your mailing address.
If you signed up for health insurance through the Health MarketPlace in the USA It is your obligation as an American citizen to report any change in your circumstances , such as:
Changes in your household income or family size.
Unemployment or deaths.
Illnesses or accidents.
Family changes may affect your advance premium tax credit payments . This means that when you report a change in circumstances, you may be eligible for a special enrollment period; this allows you to purchase health care insurance through the Marketplace outside of the open enrollment period. Remember, it will always be important that you visit the official website of the Medical Insurance in order to obtain more information on how to report changes in circumstances and special registration .
