What medical services are covered before and after your in-network and out-of-network deductible are satasfied?
There are a few different types of health plan deductibles, and the medical services that are covered before and after your deductible is satisfied can vary depending on the type of plan you have.
For example, with an in-network deductible, you may have copayments for some services before you satisfy your deductible.
Once you’ve met your in-network deductible, your copayments may go down or you may no longer have copayments for some services.
With an out-of-network deductible, you usually have to pay the entire cost of the service yourself until you reach your deductible amount.
After you satisfy your out-of-network deductible, you may still have to pay copayments or coinsurance for some services.
Depending on the type of health plan you have, you may have covered healthcare services for out-of-network providers, you may not.
What are your excluded or limited covered healthcare benefits?
Some plans may exclude or limit coverage for certain types of care, such as preventive care or services that are considered “out-of-network essential health benefits.”
Are your preferred medical providers, surgical centers, and hospitals going to be considered out-of-network?
When deciding on healthcare coverage, it’s important to understand the difference between in-network and out-of-network providers and if your preferred medical providers are out-of-network, it is important to have an understanding of what your possible financial exposure would be if you chose an out-of-network provider.
Does the health plan have out-of-network non-emergency essential healthcare benefits?
If the answer is yes, then you will likely have some financial exposure.
First, what is the out-of-network deductible? This is the amount you’ll need to pay before your health insurance starts covering expenses. Keep in mind the out of network deductible will cost more than the in-network deductible
Second, what is out-of-network coinsurance? This is the percentage of the cost of care you’ll be responsible for once your out-of-network deductible has been met.
Lastly, be aware that out-of-network non-emergency medical treatments and services may not be covered at all by health insurance.
Depending on the type of plan you choose, you may be responsible for the entire cost of care if you go out-of-network for non-emergency medical events.
What is the Out-of-network, Out-of-maximum?
This is the ultimate financial requirement before insurance pays 100% of the remaining medical expenses. Keep in mind the out-of-network, out-of-pocket maximum will be higher than your in-network financial obligations and depending on the type of health policy you could still be financially responsible for elective treatment and services if not pre-approved by your health plan.
Does your health plan have an annual maximum benefit pay-out for out-of-network providers and medical treatment?
Some medical insurance companies will set a yearly maximum and lifetime maximum payout for out-of-network providers in order to limit their financial exposure to out-of-network providers for non-emergency medical care and services.
This means that if your family were to need non-emergency medical treatment from a specialist or receive care at a hospital that is not in your insurance company’s approved network, you could still be on the hook for a lot of money if there is an annual maximum benefit pay-out for out-of-network providers.
- If Your Policy has lifetime & annual maximums, what are those limitations?