Out-of-Network Care

When you step outside the network

Every health plan has a network of providers who agree to set rates. Care from anyone outside that list is out of network. How your plan handles it depends on the plan type:

• HMO and EPO plans: usually no coverage for out-of-network care, except emergencies.
• PPO plans: coverage at a higher deductible and coinsurance, often with a separate out-of-pocket maximum.
• POS plans: some coverage, often only with a referral.

Why out-of-network care costs more

Two things drive the higher cost:

1. Higher cost sharing. Out-of-network deductibles and coinsurance are higher, and some plans have no out-of-pocket cap for out-of-network care.
2. Balance billing. Out-of-network providers have not agreed to the plan's rates, so they can bill you the difference between their charge and what the plan pays, in situations not protected by federal law.

Example

Elena has a PPO plan. She chooses a surgeon outside her network for a planned shoulder repair because a friend recommended him.

• The surgeon bills $20,000. The plan's allowed amount for out-of-network surgery is $12,000.
• Elena owes her out-of-network deductible and 40% coinsurance on the allowed amount.
• She also owes the $8,000 difference between the surgeon's bill and the allowed amount, since she chose this provider for planned care and signed a consent form.

An in-network surgeon would have cost her far less.

Protections that apply

The federal No Surprises Act limits out-of-network bills in key situations:

• Emergency care at any hospital, including out-of-network facilities.
• Certain providers at in-network facilities, like anesthesiologists, radiologists and assistant surgeons, when you did not choose them.
• Air ambulance services.

In those cases you pay in-network cost sharing, and the provider cannot balance bill you.

How to avoid surprise costs

• Confirm every provider for planned care, including the facility, surgeon and anesthesia group.
• Ask your plan for a cost estimate before major procedures.
• Read anything you are asked to sign, since consent forms can waive surprise billing protections for planned care.

Marketplace vs private plans

Most Marketplace plans in Florida are HMOs or EPOs with no routine out-of-network benefits. Private plans sold outside the Marketplace are more likely to be PPOs that do cover out-of-network care. For people who see specialists in other states, travel often, or want access to a particular hospital system, that out-of-network benefit can be the deciding factor.

Learn more in our guides on moving to Florida and health insurance and private vs Marketplace plans for the self-employed. To compare plans with and without out-of-network benefits, request a quote.