Before you seek medical attention, it's important that you understand how your health care plan works. It's also important that you understand what is covered by your health insurance, and what you may need to pay.
How can you learn more about the type of benefit plan that you have and what you will owe?
- You can call the health plan's customer service department or visit the company's web site. If you get your health benefits from your employer, you may also call your human resources department.
- Sometimes you will be told that a provider “participates" with your health plan or “accepts" payment directly from your health plan. If the provider is out-of-network, ask questions to determine how much it will cost to receive services.
- Unless it is an emergency or when you have no control over which provider you will see, you should always find out whether a provider is in-network or out-of-network before receiving services. This information is critical to know since it determines how much money you will owe. Visit the health plan's website, specifically the online provider directory to see if your health care provider participates in the plan or not. You can also call the health plan's customer service department.
What does it mean to be an “in-network" provider? What will you need to pay when you use an “in-network" provider?
Health care providers, including doctors, hospitals, and other health care professionals who are licensed or authorized to provide health care services in Maryland, may or may not have agreed to accept a set dollar amount from your health plan to provide you with covered services. If the provider has a contract with your health plan, that provider is known as an “in-network" provider. When receiving care from an in-network provider you may need to pay a copayment, coinsurance, and a deductible. Check with your health care plan and provider to find out how much you have to pay when using an in-network provider.
What does it mean to be an “out-of-network" provider?
If there is no contract between the provider and your health plan, that provider is known as an “out-of-network" provider. Your health benefit plan may not pay for services if you see an out-of-network provider and you will be responsible for the entire bill. Some health benefit plans place limits on when you can see an out-of-network provider and some plans will pay a smaller portion of the bill if you receive services out-of-network than if you go in-network. Review your plan to make sure you know the rules.
In some circumstances, you will not have to pay more for an out-of-network visit, such as in an emergency situation, when you received certain non-emergency treatment at an in-network facility, for air ambulance services, or if you were approved by your health plan to see an out-of-network provider for mental health services.
How much will you have to pay when you use an “out-of-network" provider?
When seeing an out-of-network provider, you may still need to pay a copayment, coinsurance, and deductible. You may also need to pay the difference between what your health plan paid, which is the “allowed amount" and what the provider charges; a practice known as “balance billing." In some instances, you may be required to pay the entire amount of the bill. Review your plan carefully before you receive treatment.
In some circumstances, when you go out-of-network, you may be protected from balance billing.
Under the federal No Surprises Act, you cannot be balance billed if you:
- Receive emergency services from an out-of-network provider or an out-of-network emergency facility.
- Receive covered non-emergency services from an out-of-network provider while visiting an in-network health care facility, unless you willingly give written consent in advance to give up your protections. (You can never be asked to waive your protections for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services, and you will never be balanced billed for these services at an in-network facility).
- Receive covered air ambulance services provided by an out-of-network provider of air ambulance services.
Additionally, beginning on January 1, 2023, if you are approved to see an out-of-network specialist for mental health or substance use disorder services you cannot be balance billed.
Do I have to pay the health care provider up front for services and then get reimbursed, or can my health care plan pay the provider directly?
You can pay the health care provider directly and then seek reimbursement from your plan. But you can also authorize the plan to pay the provider directly by assigning benefits. To assign benefits, you will have to sign an “assignment of benefits," which is a legal agreement that authorizes your plan to pay the named provider for health care services they provided. For example, you can assign payment to a health care provider, hospital or ambulance company.
For further information, please click HERE for a list of frequently asked questions (FAQs).
Preguntas frecuentes: Proveedores dentro de la red frente a proveedores fuera de la red
The FAQs cover when and how you may see an out-of-network provider, what happens when you have no control over receiving services from an out-of-network provider, receiving emergency services from an out-of-network provider, and what it means to assign your benefits to an out-of-network provider.