When a provider accepts your health insurance plan, they are considered in network. We also call them participating providers. When you go to a provider who doesn’t take your plan, they are considered out of network. The two main differences between them are whether your plan helps pay for care you get from out-of-network providers and, if they do, the cost.
The short answer: ask them. Plans vary widely in terms of what their out-of-network coverage includes. Most HMO plans, for example, do not cover any services with out of network providers, leaving you to pay 100% of the cost. PPO plans, however, do allow their members to access services from out of network providers. Typically, there is a deductible (The amount you pay for covered health care services before your insurance plan starts to pay. With a $2,000 deductible, for example, you pay the first $2,000 of covered services yourself) that must be met before any services are covered. This deductible can range from $200 to as much as $6000 or $7000. This is why it is important to get this information directly from your health insurance company.
At The Haffey Center, we will submit claims to your insurance company as part of the services we provide to you. We will also make an effort to determine what benefits your insurance plan provides for you for the services that you are requesting from our center. We cannot, however, be responsible for what services a specific insurance plan will cover or their willingness to actually pay for those services. Insurance companies vary widely in their policies and procedures regarding these questions. Once we have made our best effort to find out what your insurance plan covers and submitted claims for reimbursement for those services, we cannot be responsible for what the insurance company actually makes payment for. Any difference between the cost of services that have been provided and what your insurance company has paid are your individual responsibility.