The federal COVID-19 emergency is over.Cost of Out-of-Network Doctors & Hospitals
People are paying more of their healthcare costs these days. It’s no wonder there is a lot of interest in keeping these costs down.
A smart way to do this is to stay in network. We negotiate rates with providers to help you save money. We refer to these providers (such as doctors, hospitals, and surgical centers) as being “in our network.”
There may be times when you decide to visit a doctor or hospital not in the network. Some plans cover out-of-network care only in an emergency – otherwise, you are responsible for the full billed amount. For plans that do cover out-of-network care, you’ll usually pay more than if you stayed in the network.
See how much less it can cost to stay in network
Some plans do not offer any out-of-network benefits. For those plans, out-of-network care is covered only in an emergency. Otherwise, you are responsible for the full billed amount of any care you receive out of network.
The information on this page is for plans that offer both in-network and out-of-network coverage.
These plans pay for out-of-network services based on an “allowed” amount. Most Texas Health Aetna plans determine the allowed amount based on what Medicare would pay, or on a “reasonable” amount. Your plan documents will tell you how your plan determines the allowed amount.
We will use an example to show you how out of pocket costs are calculated if you stay in network and if you go out of network for the same care.
Let’s look at an $825 charge from a doctor’s visit.
In network, your cost for this visit is $140. Out of network, it’s $645 – so you pay an extra $505. Here’s why:
IN NETWORK |
OUT OF NETWORK |
The doctor bill is $825. For doctors in our network, we’ve contracted a price of $500 for this type of visit. This is all the doctor can collect. So you get a $325 discount at the start.
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The doctor bill is $825. The out-of-network “allowed” amount for this type of visit is $400. The doctor can look to you to pay the rest – in this case $425. That amount is your responsibility and is called balance billing. Your cost so far: $425 |
You pay your deductible for in-network care, which is $50. $500 - $50 leaves $450.
Your cost so far: $50 ($0 + $50) |
You pay your deductible for out-of-network care, which is $100. Deductibles for out-of-network care are usually higher than for in-network care. $400 - $100 leaves $300. Your cost so far: $525 ($425 + $100) |
Now that you’ve met your deductible, your plan pays 80% of the rest. In this case, that’s $450. Your plan pays $360 (80% of $450).
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Now that you’ve met your deductible, your plan pays 60% of the remaining allowed amount. In this case, that’s $300. Your plan pays $180 (60% of $300). You pay the other 40%, or $120. We call this your coinsurance. We pay a smaller percentage for out-of-network care than for in-network care. That means your coinsurance (the percentage you pay) is higher. Your total cost: $645 ($425 + $100 + $120) |
How does going out of network affect out-of-pocket limits?
An out-of-network doctor can charge any amount he or she wants. He has not agreed to a contract price for the covered service. In this case, the doctor is charging $825. Not all of that money counts toward your out-of-pocket limit.
- Your out-of-network deductible ($100) counts toward your out-of-pocket limit.
- Your coinsurance ($120) counts toward your out-of-pocket limit.
- The extra amount the doctor can bill ($425) does not count toward your out-of-pocket limit.
How to lower your costs
Ask your doctor to refer you to a specialist, hospital or surgical center that accepts your plan.
Or search our provider directory >
Find out what it will cost before you go. Ask your out-of-network providers what the billed amount will be. For in-network care, your secure member website may be able to provide rate estimates. Or talk with the in-network provider’s office about what you may be asked to pay.
Does your member ID card have “NAP” on the front? That stands for National Advantage™ Program. And it has benefits for you:
- You can get discounts for out-of-network care from NAP providers. Your out-of-pocket costs may be less than your costs for seeing other providers who are out of network.
- If you get care from a NAP provider, you won’t get a balance bill. You will pay your usual cost sharing for out-of-network care.
Check your most recent ID card to see whether your plan has the program. Some plans that used to have NAP no longer have it.
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