Save money by staying in network
Maybe you’ve read that one of the best ways to save on health care costs is to “stay in network.” But you’re not sure what that means.
You’re not alone. Many people find the term confusing. We’re here to help you understand. A network is a group of health care providers. It includes doctors, specialists, dentists, hospitals, surgical centers and other facilities. These health care providers have a contract with us.
As part of the contract, they provide services to our members at a certain contract rate. This rate is usually much lower than what they would bill if you were not an Innovation Health member. And they agree to accept the contract rate as full payment. You pay your coinsurance or copay along with your deductible.
Some plans do not offer any out-of-network benefits. For those plans, out-of-network care is covered only in an emergency. Otherwise, you are responsible for the full billed amount of any care you receive out of network.
The information on this page is for plans that offer both in-network and out-of-network coverage.
How much you can save
You can see detailed examples of how much you might save – on the same service – just by staying in network.
PDF – Save money with Innovation Health’s medical provider network
Why out-of-network care costs more
There may be times when you decide to visit a doctor not in the network. If you go out of network, your out-of-pocket costs are usually higher. There are many reasons you will pay more if you go outside the network. Keep reading to learn more.
The health plan pays less
Your Innovation Health health benefits or insurance plan may pay part of the doctor’s bill. But it pays less of the bill than it would if you got care from a network doctor.
Also, some plans cover out-of-network care only in an emergency.
Out-of-network rates are higher
An out-of-network doctor sets the amount to charge you. It is usually higher than the amount your Innovation Health plan “recognizes” or “allows.”
We do not base our payments on what the out-of-network doctor bills you. We do not know in advance what the doctor will charge.
An out-of-network doctor can bill you for anything over the amount that Innovation Health recognizes or allows. This is called “balance billing.” A network doctor has agreed not to do that.
Cost sharing is more
What you pay when you are balance billed does not count toward your deductible. And it is not part of any cap your plan has on how much you have to pay for covered services.
Many plans have a separate out-of-network deductible. This is higher than your in-network deductible (sometimes, you have no deductible at all for care in the network). You must meet the out-of-network deductible before your plan pays any out-of-network benefits.
With most plans, your coinsurance is higher for out-of-network care. Coinsurance is the part of the covered service you pay after you reach your deductible (e.g. the plan pays 80 percent of the covered amount and you pay 20 percent coinsurance).
You’ll have more work, too
What you pay when you are balance billed does not count toward your deductible. And it is not part of any cap your plan has on how much you have to pay for covered services.
Many plans have a separate out-of-network deductible. This is higher than your in-network deductible (sometimes, you have no deductible at all for care in the network). You must meet the out-of-network deductible before your plan pays any out-of-network benefits.
With most plans, your coinsurance is higher for out-of-network care. Coinsurance is the part of the covered service you pay after you reach your deductible (e.g. the plan pays 80 percent of the covered amount and you pay 20 percent coinsurance).
How we determine what to pay for out-of-network care
The plan you have determines how much you pay for out-of-network care. The exact amount depends on the:
- Method that your plan uses to set the “recognized” or “allowed” amount
- Percent of the allowed amount to be paid by the plan (like 80 percent or 60 percent).
Your plan may base the allowed amount on a rate schedule from:
- Medicare-based rates, which are determined and maintained by the government,
- “Reasonable”, “usual and customary” and “prevailing” rates, which are obtained from a database of provider billed amounts
- Other types of rate schedule
To find the method and percent, check your plan documents. Or contact us at the toll-free number on your member ID card.
PDF – Read more about how we pay for out-of-network benefits
See how we might calculate costs for an out-of-network office visit
You are covered for emergency care
- You are covered for emergency care. You have this coverage while you are traveling or near your home. That includes students who are away at school.
- When you need emergency care (for example, due to a heart attack or car accident), go to any doctor, walk-in clinic, urgent care center or emergency room. When you have no choice, we will pay the bill as if you got care in network. You pay your plan’s copayments, coinsurance, and deductibles for your in-network level of benefits.
- We’ll review the information when the claim comes in. If we think the situation was not urgent, we might ask you for more information and may send you a form to fill out. Please complete the form, or call Member Services to give us the information over the phone.
Health benefits and health insurance plans are offered and/or underwritten by Innovation Health Insurance Company and Innovation Health Plan, Inc. Innovation Health Insurance Company and Innovation Health Plan, Inc. are affiliates of Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services to Innovation Health.
