Out-of-Network Benefits

What do you know about your health insurance plan?

Do you have out-of-network benefits?

Do you need a referral from your PCP to see a specialist?

What's your annual deductible?

Health insurance is confusing.

Surprisingly, most New Yorkers know very little about health insurance.

Which, should be shocking, given the high cost of premiums.

So, what are you paying for?

How can you maximize value from your health insurance?

Health Insurance Plans

There are four main types of health insurance plans: HMO, EPO, POS & PPO.

Don't feel intimidated by this alphabet soup; the differences are rather straightforward ;)

HMO [Health Maintenance Organization]: The most basic of the four types, an HMO places your primary care physician [PCP] as the quarterback for your plan. The PCP must provide a referral to see a specialist and only in-network specialists can be seen. This means an HMO does not reimburse for any services rendered by an out-of-network provider. The upside to limited, controlled choice? Lower monthly premiums.

EPO [Exclusive Provider Organization]: Like an HMO, an EPO focuses exclusively in network and does not provide out-of-network benefits. However, compared to an HMO, an EPO has the advantage of not requiring a PCP referral to see a specialist. This means you can head straight to the gastroenterologist for an endoscopy without a PCP referral. The cost of being able to bypass your PCP? Higher monthly premiums than an HMO.

POS [Point of Service]: Like an HMO, POS requires a referral from your primary doctor to see a specialist. However, POS offers something that neither an HMO nor an EPO offers: out-of-network benefits. This means a POS will reimburse some or all of the costs of out-of-network services, after meeting your annual deductible.

PPO [Preferred Provider Organization]: The most comprehensive of the four plans, the PPO offers the greatest freedom and reimbursement of all plans. Want to see a specialist without a referral from your PCP? Go for it. Want to see out-of-network providers? Simply submit a receipt to your health insurance for reimbursement. The trade off? The highest monthly premiums of the four plan types.

The four types of health insurance are easily divided into a 2x2 grid asking: 1) Do you require a referral from your PCP [Primary Care Provider] to see a specialist? and, 2) Do you have out-of-network benefits? Plans with out-of-network benefits are aligned with reimbursement for services by Doctor K, whereas HMOs and EPOs will not reimburse for services provided by Doctor K.

The four types of health insurance are easily divided into a 2x2 grid asking: 1) Do you require a referral from your PCP [Primary Care Provider] to see a specialist? and, 2) Do you have out-of-network benefits?

Plans with out-of-network benefits are aligned with reimbursement for services by Doctor K, whereas HMOs and EPOs will not reimburse for services provided by Doctor K.

Although Doctor K does not participate with insurance providers, two of these plan types integrate well with Doctor K's services: POS [Point of Service] & PPO [Preferred Provider Organization].

Doctor K provides a superbill for all services rendered, which can be submitted for reimbursement to your insurance company. Once the deductible has been met for the year, your insurance will pay some or all of the costs of out-of-network services.

For instance, let's say you have an annual deductible of $500, an out-of-network coinsurance of 10% and an out of pocket maximum of $5,000. After spending $500 on healthcare for the year, your insurance will pay 90% of out-of-network costs while you pay the remaining 10%, known as co-insurance. So, after meeting your deductible, a $300 out-of-network visit with Doctor K will cost you $30 and your plan would pay $270. If your medical expenditures exceed your yearly out of pocket maximum, your insurance plan will pick up 100% of medical expenses for the remainder of the year.

Have questions about the benefits of your health insurance plan?

Email services@DoctorK.nyc for more information.


Resources

Artwork from "3 Questions to Decide If You Should Use Your Insurance" <http://www.athletespotential.com/blog/3-questions-to-decide-if-you-should-use-your-insurance>