Question: What happens if I end up needing care from a doctor who isn’t in my health plan’s network?
Answer: Insurers are not required to cover any care received from a non-network provider, though all PPO plans sold in California today do, at least to some extent. If you do receive care out of network, it could be costly for you. Generally plans that provide an out-of-network option cover such care at a lower rate (e.g., 80% of in-network costs versus only 50% of non-network costs.) In addition, insurers are not required to apply your out-of-network costs to the annual out-of-pocket maximum. Non-network providers also are not contracted to limit their charges to an amount the insurer says is reasonable, so you might also owe “balance billing” expenses.