When To Go Out of Network for Health Care

If you’re like the majority of  Americans, your health care insurance is provided through a Preferred Provider Organization (PPO) or a Health Care Maintenance Organization (HMO). With a PPO, you probably have the option of using an out-of-network provider, but your out-of-pocket expenses such as co-pays will be cheaper if you stay in network.  With an HMO, you usually don’t have the option of going out of network and your insurance won’t pay for anything, except in very limited, pre-defined circumstances. With either type of health insurance coverage, you need to understand when it makes sense to go out of network.  Be aware, however, that every health insurance plan will differ, so this information is for general purposes. If you want to be absolutely certain about the conditions under which your plan allows you to go out of network and the financial ramifications, consult your plan administrator.

Real Emergency

Most plans include some provision for seeking out-of-network care in a real emergency. If you feel you or a covered family member is in a life-threatening situation, go to the nearest emergency care facility (ideally by ambulance). Then cover your financial bases by informing your insurance company and/or your primary care physician. If you do this within 48 hours of emergency treatment, you’ll greatly improve the odds that some portion of your out-of-network emergency care will be covered. Obviously, it helps to know before you need emergency care what your health insurance policy considers a genuine emergency.

Natural Disaster

Earthquakes, tornadoes, floods, firestorms, hurricanes and other natural disasters may make it impossible for you to get in-network care. If you’ve been forced to evacuate or if your network emergency facility has been destroyed, get the care you need wherever you can get it. If possible, document the circumstances, in case your provider questions your claim. In some cases, when the government declares a natural disaster, you may be able to qualify for in-network rates.

Away From Home

If you or a covered family member becomes ill or is injured while out of town on vacation or business, your health insurance probably will cover your out-of-network care at  in-network rates. However, unless you’ve got a real emergency, call your health insurance company first to see if they have a preferred provided where you are.

You Live in the Boondocks

In many cases, health insurance companies will make exceptions and provide in-network rates if you live too far from an in-network provider to make it practical for you to receivenecessary on-going specialist care from a network provider.

Other times when it might make sense to go out of network would be if you’re receiving specialized care and your network does not include that type of specialist, or the specialist has left the network. Weigh the advantages and disadvantages for your particular situation.


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