It’s confusing, it can be pricey, and there are several household chores you’d rather do, than deal with it… It’s your health benefits. But don’t worry, you can do this. Consider this your health benefits 101.
Out-of-Network health care services and providers: you’ve heard of it, or you’ve seen it alongside “in-network” health care in the materials from your health plan at enrollment. What does it mean? As a general rule: out-of-network health care services cost you more than in-network health care services in upfront costs.
This is all part of the networks used within the health care system. Networks consist of select providers or hospital systems and the doctors and clinics associated with those systems. Your health plan likely utilizes a Network Provider.
In a PPO (Preferred Provider Organization) health plan or a POS (Point of Service) health plan, you may have the option to go wherever you wish for health care. That’s a great thing, but getting out-of-network health care may put a serious dent in your wallet.
When determining where to go, you might have a choice between in-network and out-of-network providers. When considering where to get your health care, here are a few rules of thumb:
- In-Network providers have negotiated costs and/or delivery standards with your health insurer
- Your health insurer provides health plans that encourage you to seek In-Network care
- If you use In-Network providers, your out-of-pocket costs (deductible, copays, maximum out-of-pocket) are sometimes much lower
Out-of-network providers may “balance bill” you, as well.
Balance billing is when the insurer agrees to pay only a percentage of the costs of care and the provider bills you for the remainder. For example: the cost of an outpatient surgery comes to $11,000, but the insurer only pays 80% of the cost (or $8800). So, after you have paid your out of pocket expenses, you are also billed for an additional $2200. That’s balance billing.
Why is it this way?
Networks ultimately help people who have health coverage from insurance carriers, and this a way for the carriers to control rising costs of health insurance. When an insurance carrier aligns their coverage with a network, that network gives the carrier a discount on the price of its health care services.
Since the discount can be anywhere between 10%-30% of the retail cost, the health plan passes the savings on to you when you use in-network providers and services.
Which providers are in-network?
A list of in-network providers is often available from your health insurance company. However, it is important to always directly confirm with a provider that they are a network provider for your health plan before receiving services from that provider.
Unfortunately, you cannot always rely on network provider listings on the internet to be up-to-date. Just as you can change your job, a health care provider can change its arrangement with an insurance company.
When in doubt, ask questions
For any given health situation, it is important to find out whether ALL your providers are in-network. This includes the individuals who treat you, as well as the location of your health care services.
For example: the surgical center is in the network, as well the surgeon. But the radiologist is not in-network and neither is the anesthesiologist, which leaves you paying out of network costs for the radiologist and the anesthesiologist. So, ask yourself, “is the radiologist in-network? Is the anesthesiologist?”
When in doubt, ask questions of your health care providers, who are there to serve you and answer questions about networks and health plan coverage.
Providers not necessarily in one particular network include:
- Mental health services
- Ambulance (or other emergency transport service)
- Dialysis centers
Figuring out your health plan can be tricky. There can be a lot of information to deal with. But, the more general concepts that you know, the better equipped you will be. You can make educated choices!
Empower yourself to proceed confidently when making decisions about health care coverage for you and your family. Health Benefits 101 can help you understand the basics. Recognizing your needs and preparing can help you to know what to expect and how to deal with it.
Check your health plan documents
But wait, there’s more! This is a description of what it means to use out-of-network health care, but that isn’t the whole picture. Check your Summary Plan Description (SPD) from your health insurance company to know the specific rules of your health insurance plan. Don’t know what health insurance plan you have? Ask your employer or check your mail for your insurance card.
If you want to learn more about the plans and services we provide you, please access your Summary Plan Description (SPD) and other helpful information by logging in to your Employee Benefits Corporation participant account.
- Click the “Log In” button in the upper right corner of this page
- (You can also bookmark and navigate to www.ebcflex.com any time from any web browser on desktop or mobile)
- Select “Participants” from the dropdown menu
By logging in you’ll find specific rules for your BESTflexSM Health Care Flexible Spending Account (FSA), your EBC HRASM Health Reimbursement Arrangement (HRA), or your SimplyHSA Health Savings Account (HSA). These benefits give you a way to save pre-tax money on your out-of-pocket health care expenses.
You can also log in to access helpful information about your CommuteEase pre-tax parking or transit benefit, information for COBRASecure users, or BESTflex Dependent Care Flexible Spending Account (DCFSA).
Not sure what Employee Benefits Corporation plan you have? Log in at the top of the page to see all your current plans (www.ebcflex.com), or ask your employer.