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Health 
The Fine Print
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Participating provider directory. |
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Out-of-Network Reimbursement | |||||||||||||||||||||
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Rates | |||||||||||||||||||||
1. |
Most people today try to utilize health providers within their insurance company's network. In fact, approximately 95% of paid claims are from in-network providers. The only direct costs to you are the copayments (know as copays) which you pay with each visit to an in-network provider. (These copays generally range from $10-20 per visit). |
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2. |
If your plan provides for benefits when you use out-of-network providers, you are required to pay up to the amount of your deductible. Once your deductible is met, you will be reimbursed a percentage of your costs — this percentage is known as coinsurance. Your coinsurance may vary from 50% to 90%, and will usually rise to 100% after you accumulate a large amount of bills (this is called stop loss). Your coinsurance benefits will depend also on what the insurance company feels is the usual, reasonable and customary (UCR) fee for the service provided. Each insurance company uses a different fee schedule, and these schedules will vary significantly from company to company. When comparing medical plans, you should ascertain the UCR percentile being applied. This may vary from the 60th to 90th percentile. (The industry standard is the Health Insurance of American Association (HIAA) 80th percentile.) |
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3. |
A plan which is more expensive is not necessarily better. Rates will vary based upon copays, deductibles, coinsurance percentages, etc. If you intend to stay with in-network providers only, you should strongly consider high deductibles and low coinsurance — both of which will reduce the cost of your premiums. You should also consider whether your in-network primary-care physician (PCP) is restricted in the choice of hospitals to which you can be referred. Note: Not all provider networks are the same from your doctors' point of view, as well. Some medical plans pay doctors a flat fee no matter how many times the patient is seen — known as capitation. Other plans pay providers for each service rendered — known as fee for service. |
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