When a doctor, hospital or other provider accepts your health insurance plan we say they’re in network. We also call them participating providers.
When you go to a doctor or provider who doesn’t take your plan, we say they’re out of network.
The two main differences between them are cost and whether your plan helps pay for care you get from out-of-network providers.
When a provider joins our network, they agree to accept our approved amount for their services. For example, a doctor may charge $150 for a service. Our approved amount is $90. So as a Blue Cross member, you save $60.
On your claims and explanation of benefits statements, you’ll see these savings listed as a discount.
Doctors or hospitals who aren’t in our network don’t accept our approved amount. You’ll be responsible for paying the difference between the provider’s full charge and your plan’s approved amount. That’s called balance billing.
PPO versus HMO
When it’s a medical emergency or you can’t wait for a doctor’s office to open, go to the nearest hospital or urgent care. In or out of network, all plans help pay for medically necessary emergency and urgent care services.
When it’s not an emergency, PPO and HMO plans work differently.
HMO plans don’t include out-of-network benefits. That means if you go to a provider for non-emergency care who doesn’t take your plan, you pay all costs.
PPO plans include out-of-network benefits. They help pay for care you get from providers who don’t take your plan. But you usually pay more of the cost. For example, your plan may pay 80 percent and you pay 20 percent if you go to an in-network doctor. Out of network, your plan may 60 percent and you pay 40 percent.
How to find in-network providers
Call your broker or health insurance provider to see if your doctor or hospital is in-network. Before you go to a doctor or hospital, it’s always a good idea to call and ask if they take your plan.
Cosmo Insurance Agency is an independent insurance agency serving surrounding communities in New Jersey. Cosmo keeps its promise to assure an efficient and creative approach to the services we offer. Each of our clients experience a personalized and long-term relationship with us. Our New Jersey based team of health brokers guides our clients in helping them choose the most cost-effective options. By incorporating the latest in technology-based tools and laws on healthcare, employee benefits, life insurance and finance, we keep our clients up-to-date with the plans that encompass all of their needs, whether it is individual or group insurance.
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