Insurance can be tricky to navigate, especially if you’re looking to use it to cover prescriptions and appointments with specialists to manage your health properly. Your network of medical providers, listed on your insurance provider’s portal or website, is a group of doctors, hospitals, and other healthcare providers who agree to take your insurer’s rate. Typically, in-network providers are 100 percent covered or have a small copay associated with them.
However, a specialist you need to visit may be out-of-network (OON)—meaning the costs can quickly add up without the coverage from your insurance. So, should you bite the bullet and go with an OON provider? Here are a few tips to help you decide and pay for your appointments.
Your insurance plans
Depending on your plan, you could be eligible for a few OON benefits. If not, there are still options. Note: this is for non-emergent care. Any emergency care on any insurance plan should be at least partially covered.
An HMO plan typically only covers in-network and emergency care, which does not include any OON benefits, like reimbursement, which means you are responsible for all costs of an OON provider. However, there are still a few options to reduce costs if you need one.
PPO plans still have a list of in-network providers and cover emergency care, but they will often include OON benefits. Check your plan’s coverage percentage. For example, the insurance company may cover eighty percent of an OON provider, and you will need to pay for the remaining twenty percent out of pocket.
PPO plan users
Examples of common OON health professionals
If you have OON benefits, there are a few common OON providers people turn to for care that insurance companies are typically good about reimbursing. So, if you’re looking into any of the following OON providers, look closely at your plan to see if it’s partially or 100 percent reimbursable.
- Therapists and psychiatrists
- Physical therapists
Most PPO plans reimburse your OON care based on a percentage of UCR (Usual, Customary, and Reasonable) charges, which is the usual rate for other providers to pay in that geographic location. They perform their market research to determine what is fair for them to cover. Considering this, do your research beforehand to compare your potential OON provider to others in the area to ensure their prices are reasonable and that your insurance will cover most of the costs.
HMO plan users
HMO plans may not cover the costs of any OON providers, but there are still options to reduce the costs.
With an HMO plan, you’ll choose your primary care physician (PCP), through which all your health services go through. However, you can still see other providers through a referral. For example, if you ask your PCP about seeing a dermatologist for severe acne, they can hand you a referral that recommends an in-network dermatologist for a specific procedure or care plan.
Look for small businesses
Some health professionals open private practices that don’t work through insurance at all. The advantages are that they are used to working with people’s budgets, they can have flexible prices with discounts for students or veterans, and you’ll be supporting a small business in your area.
If you’re interested in a specific type of care, like chiropractic, look on apps like Groupon for deals on appointments in your area. There are typically holistic healthcare appointment coupons available, such as massage, chiropractic, acupuncture, and skin care appointments.
Dealing with mental health issues alone can be draining. If you have been searching for an in-network provider with no luck, consider teletherapy. Websites like BetterHelp offer competitive discounts and rates for high-quality, online therapy—which can be much cheaper than in-person therapy.
Consult your insurance agent and a financial advisor for help understanding your OON and healthcare budgeting options.