Out-of-network care | Missouri Department of Insurance

What does “going out of network” mean for me?

When your health care provider “goes out of network”, it means they don't have a contract with your insurance plan to provide services. You are still insured, but out-of-pocket costs may increase if you use out-of-network providers.

Understanding networks and out-of-pocket costs is important. To help you better understand networks and out-of-network costs, here are some key points to keep in mind:

In-network providers typically have lower out-of-pocket costs than out-of-network providers.
If you see an out-of-network provider, you may be responsible for paying the difference between the provider's charges and what your insurance company will pay.
Some plans offer out-of-network coverage, which may come with higher deductibles, copays, and coinsurance amounts.
If you have a specific provider or facility in mind, it's important to check if they are in-network before scheduling an appointment.
When traveling, it's important to understand your plan's out-of-network coverage.

Some exceptions:

Emergency Services: A facility or a provider may not bill you more than your in-network cost sharing amounts for emergency services, even if the facility providing the emergency services is out-of-network. If you are experiencing an emergency, don't hesitate to seek immediate medical attention even if the provider is not in your network.
Specialty Care: Sometimes, you need to see an out-of-network provider because specialized care is unavailable in your network. This may require your insurance company to provide prior authorization before your services are approved for payment, or to make other arrangements for you to get the care you need. Talk to your doctor and insurance company to determine your options.

Missouri State Employees visit MCHCP for more information.

Definitions

Cost Sharing

Your share of costs for services that a plan covers that you must pay out of your own pocket (sometimes called “out-of-pocket costs”). Some examples of cost sharing are copayments, deductibles, and coinsurance. Family cost sharing is the share of cost for deductibles and out-of-pocket costs you and your spouse and/or child(ren) must pay out of your own pocket. Other costs, including your premiums, penalties you may have to pay, or the cost of care a plan doesn’t cover usually aren't considered cost sharing.

Coinsurance

Your share of the costs of a covered health care service, calculated as a percentage (for example, 20%) of the allowed amount for the service. You generally pay coinsurance plus any deductibles you owe. (For example, if the health insurance or plan’s allowed amount for an office visit is $100 and you’ve met your deductible, your coinsurance payment of 20% would be $20. The health insurance or plan pays the rest of the allowed amount.)

Copayment

A fixed amount (for example, $15) you pay for a covered health care service, usually when you receive the service. The amount can vary by the type of covered health care service.

Deductible

An amount you could owe during a coverage period (usually one year) for covered health care services before your plan begins to pay. An overall deductible applies to all or almost all covered items and services. A plan with an overall deductible may also have separate deductibles that apply to specific services or groups of services. A plan may also have only separate deductibles. (For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible.)

Out-of-network Provider (Non-Preferred Provider)

A provider who doesn’t have a contract with your plan to provide services. If your plan covers out-of-network services, you’ll usually pay more to see an out-of-network provider than a preferred provider. Your policy will explain what those costs may be. May also be called “non-preferred” or “non-participating” instead of “out-of-network provider”.

Prior Authorization

Approval from a health plan that may be required before you get a service or fill a prescription in order for the service or prescription to be covered by your plan.

(Source: healthcare.gov/glossary)

Balance Billing

Balance Billing occurs when a provider bills you for the balance remaining on your bill after your health insurance company has paid its portion. The balance bill amount is the difference between the amount the provider charges and the price the insurance company sets (sometimes called the “allowed amount,” “negotiated rate,” “eligible expense,” or “payment allowance.”), after the patient pays applicable copayment, coinsurance, or deductible amounts. Generally, in-network providers are not allowed to balance bill you for covered services.

(Source: Insurance.mo.gov - No Surprises Act)

Helpful Links

No Surprises Act Page

MCHCP

HealthCare.gov