Preferred providers are groups of doctors and other care providers that your insurance company has agreed to pay at a contracted rate. Though there are some exceptions, if you choose to see doctors that are outside of this list, the insurance company will either pay less or not pay anything for services you receive.
Care given in hospitals designated as “in network” is paid for by your insurance, while care given in hospitals “out-of-network” usually is not paid by your insurance company and becomes your responsibility.
It is important for you to understand these terms and how they can affect insurance reimbursement and additional out-of-pocket expenses you might have to pay.
Frequently Asked Questions (FAQs)
Can I see doctors and other providers not participating in my health plan?
While it is possible to get a referral outside of your plan, managed care plans don't often approve care from out-of-network doctors or other providers, such as clinical psychologists, physical therapists, etc.
You may need to pay for all or some of the charges by an out-of-network provider. Check your plan for details. There are preferred provider organizations (PPOs) that enable you to see providers outside of your plan, but additional fees will be required.
Will my child’s health care be paid for if he is injured when we are out of town?
Health care for serious problems that are covered by your plan will most likely be paid. A provision of the Affordable Care Act (ACA) requires that out-of-network emergency services be covered with the same level of coverage as in-network emergency services. Elective services will probably not be covered.
Check with your plan for details, such as whether you need prior approval from your pediatrician for acute but not emergency medical care.
Note: Exemptions may be made for college students attending school away from home.
What is a “true emergency”?
Most managed care plans define a “true medical emergency” as a sudden, unexplained or possibly life-threatening medical situation, or a very severe illness or injury for which you do not have time to call your pediatrician.
Most plans will pay for emergency room care in a true emergency.
Follow-up care (such as removing stitches) should be done in your pediatrician's office. Your plan will not pay for follow-up care done in the emergency room.
Where can I take my child for treatment in a true emergency?
A provision of the ACA requires insurers to provide identical coverage for in-network and out-of-network emergency care, which allows patients to seek care at any emergency department without fear of unexpected out-of-pocket expenses.
In any life-threatening emergency, always call 9-1-1.