Out-of-networks are groups of physicians, hospitals, or other healthcare providers that have not signed a contract agreeing to accept the insurer’s negotiated prices.
If you are on an HMO and visit a doctor outside your network, you will pay the ENTIRE bill, and that cost will not apply to your max out-of-pocket expenses or toward your deductible. If you are on a PPO and visit an out-of-network doctor or facility, the plan will most often pay a smaller coinsurance percentage, based on usual and customary in-network services, but only after your deductible has been met.
On the majority of HMO plans, if you visit your primary care doctor, you will pay a copay, ranging from $15 to $50, before your deductible is met. Visits to an in-network specialist vary by plan, sometimes you have to meet the deductible, and sometimes you will have a copay ranging from $40 to $100. Occasionally exceptions to HMO rules prohibiting payments to out-of-network providers may apply in emergency situations, but you will need to read your policy to review your specific provisions.
