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Blue Mountains
Blue Mountains

In-Network and Out-of-Network Benefits

 

What’s the difference between in-network and out-of-network benefits?

·         The answer to that question could affect how much you pay for your mental health care services.

·         If the therapist you visit is part of your insurance company’s network, you'll get your mental health care at lower prices. But if you go out of your network for health care, it can become a lot more expensive.

·         If you have an HMO or EPO plan, you'll usually pay all costs for care you get outside of your plan's network So it's important to carefully consider which therapists are in a plan's network before you schedule an appointment.

 

 

Preferred Provider Organization (PPO plans)

Here's an example of how insurance in-network and out-of-network benefits compare in a PPO plan.

·         You go to a therapist that's in network and the total charge is $100. A discount is applied to that amount for our negotiated rate with the therapist. The discount is $43. The insurance company pays $57. You do not pay anything unless your deductible has a balance.  If you have a deductible, you must pay the $57 out of pocket to be applied to the deductible.

 

·         Now let's say you go to a therapist that's out of network. No discount is applied to the total charge. Insurance may or may not cover therapy. 

 

§  If covered, insurance will pay $57 and you will be responsible for the remainder. 

§  If not covered, you will be responsible for the full rate which will be applied to your deductible.

·         Going out of network could mean you'll have to pay a larger percentage of the cost or the total cost, depending on your particular plan. You may also pay a higher coinsurance percentage and have higher annual coinsurance and out-of-pocket maximums.

 

 

Health Maintenance Organization (HMO) and Exclusive Provider Organization (EPO) plans

·         HMO plans and EPO plans are different. These plans usually don't have any coverage for out-of-network care.

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