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Covered California Q&A

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 Consequences?

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Question: I went to a doctor who is not in my health plan’s network. What now?

Answer: PPO plans cover some of your out-of-network medical expense. HMO and EPO plans cover only emergency non-network expenses. Generally plans that provide an out-of-network option cover such care at a lower rate, for example a Silver Plan covers 80% of in-network costs after deductible versus only 50% of non-network costs after deductible. In addition, the out-of-network deductible is twice as much as the in-network deductible, $5,000 vs $2,500 for Silver plan. Finally, the annual out-of-pocket maximum for the Silver Plan in-network id $6,800, meaning you are covered 100% after your out-of-pocket expenses on covered items reaches $6,800 in a calendar year. The annual out-of-pocket maximum for the Silver Plan out-of-network is $9,800 and it’s separate from the in-network maximum.

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