Insurance: Know when you're covered, know when you're not

The doctors you need aren't always in your plan. And when they aren't, you need a plan. "It
Sandusky Register Staff
May 24, 2010

The doctors you need aren’t always in your plan.

And when they aren’t, you need a plan.

“It becomes very important to pick up the phone and see what’s available to you,” said Mohit Ghose, senior vice president of Public Affairs America’s Health Insurance Plans based in Washington, D.C.

America’s Health Insurance Plans represents companies that provide health care services to more than 200 million Americans.

When people change jobs and acquire a new health insurance plan, they may find their doctors or specialists  out of the loop, meaning they aren’t on their Health Maintenance Organization list or in their Preferred  Provider Organization network. Some patients may also want  to see a certain specialist because of reputation or recommendation, who may not be on their list.

Unlike in years past, most insurance providers have an out-of-network plan or procedure.

“It really depends on the medical situation (a patient) is in,” Ghose said.

But the decision to choose a physician outside of your network or plan can be costly.

The provider will most times  pay 80 percent of the negotiated price for an in-network doctor, not the actual cost of the procedure from an out-of-network doctor.

“Without having the negotiated rate that your insurer gets  for you, the consumer is  exposed to a larger percent of  the cost-sharing,” Ghose explained.

Seeing an out-of-network  physician may also require  patients to submit insurance claims themselves, rather than through their doctor.

But Ghose said many people will be able to receive the care that  they need within their health care plan.

“Most plans today have very broad networks,” he said. “Most Americans today will have multiple physicians in a variety of fields available  to them.”