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Covered California and Obamacare related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the Covered California and Obamacare knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.

Out-of-Network Reimbursement Rate?

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Question: I am trying to find a plan that will cover out of network mental health treatment. I have been seeing a very costly therapist and am hoping that by enrolling in an expensive insurance plan, i can decrease that monthly amount by a bit. It is very hard to find information about out of network coverage on insurance websites- i mostly find a line that says "copay will be higher". I was looking at blue cross blue shield ppo plans. am i correct in assuming that if my therapist bill is 250 a session- they will cover only 50%? so, i would pay 125+ office visit (35 for higher plans)? Are there any better options?

Answer: Out-of-network benefits are reimbursed at a level much lower than 50% of the provider charges. The plan pays 50% of the carrier's allowable amount, not the provider's bill. For example: your therapist charges $250 per session. The insurance company's in-network allowable amount for this treatment could be as low as $75. Your benefit amount would be half of $75, not half of $250. In addition, out-of-network coverage has a separate deductible, usually 150% to 200% of the in-network deductible. Long story short, out of network coverage sucks. Better option? Find another therapist.

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Not only are out-of-network benefits significantly reduced compared to in-network benefits, but using the example that Phil provided, if the total bill is $250, and the allowable in-network expense is $75, the unpaid difference between $250 and $37.50, $212.50, will be your responsibility, and is known as “balance billing.”

Your PPO/POS health plan has one deductible for in-network expenses, another for out-of-network expenses (which may or may not apply to behavioral health charges), as well as different out-of-pocket maximums for in-network and out-of-network expenses. In either circumstance, balance-billed amounts are not applied to deductibles or out-of-pocket limits, so each one of those $212.50 payments is completely your uninsured responsibility.

As Phil recommended, it is always best to attempt to stay within an insurer’s contracted network.

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