In-Network Vs. Out-of-Network Costs
Out-of-network costs can add up quickly, even for routine care. If you have a serious illness or injury, it can mean paying thousands of dollars more. Here's an example of doctor charges for a surgery1:
You choose an out-of-network doctor: | You choose an in-network doctor: |
|---|
Doctor charges $15,000. | Doctor charges $15,000. |
Your plan will cover $10,000. | Your plan will cover $10,000, the contracted rate. |
Doctor bills you for the $5,000 difference. | Doctor is not allowed to bill you for the difference. |
Provider Networks
When you choose a plan, you will typically have access to a specific provider network. Some networks may be larger than others or may include different choices of providers in your local area. It's important to understand these differences when choosing a plan to meet your specific needs. Also, when you choose a plan, make sure your provider is part of the network associated with that plan.
Provider Network Frequently Asked Questions
Which hospitals can I use?
If you have a Cigna HealthcareSM plan or are considering enrolling in a Cigna Healthcare plan, find out which network is included and then search our provider directory.
Do I need to see a doctor within my plan's network for my expenses to be covered?
Plans may vary, but in general to save on out-of-pocket costs, you should visit in-network providers. If your plan includes out-of-network benefits, eligible expenses are covered but your out-of-pocket costs may be higher. Depending on the plan you choose and where you live, network availability may vary. Refer to your plan documents for network details. When you've decided which plan you'd like, you can visit the provider directory to see if your providers are in-network.
Do I need to select a primary care provider (PCP) before my coverage begins?
If you are purchasing Individual and Family Plan coverage through a state or federal marketplace, a primary care provider (PCP) may be assigned to you. You may change your PCP after your planned start date.
If you are enrolling in a health plan through your employer, review your employer's plan details to see if you're required to choose a PCP or if choosing a PCP is optional, and to see if there are any network requirements for your plan.
Do I need a referral to see a specialist?
Depending on your plan, a referral from your PCP may be required to see a specialist. Under all plans, referrals are not required for OB/GYNs for covered obstetrical or gynecological services. See your plan documents for details.
Am I covered outside of the service area and outside of the country?
Depending on your plan, benefits may or may not include out-of-network coverage. Refer to your plan documents for important coverage information. Outside of the United States, coverage is limited to emergency services as defined in the plan documents. If you receive coverage through your employer, your employer may offer coverage for health care services received outside of the country when you are travelling for work purposes. Contact your employer for details.
Can I go to any health care provider if I'm traveling?
Depending on your plan, benefits may or may not include access to in-network and out-of-network benefits while traveling. Coverage and reimbursem*nt varies by plan. Refer to your plan documents for details.
Reference the provider directory to find health care providers in your plan's network. Emergency services are always covered2.
FAQs
Many health plans list an amount that is the most they'll pay for a certain service received out-of-network. If the doctor or facility charges more than your plan is willing to pay, you could be responsible for paying the difference in addition to your deductible, copay, and/or coinsurance.
What is the difference between in-network and out? ›
In-network just means that your health care provider signed an agreement with your health insurance carrier to accept a discounted rate. And out-of-network just means that there's no signed agreement in place. But there's more you should know.
What does it mean if a physician is out-of-network? ›
Providers that are out-of-network are those that do not participate in that health plan's network. The provider is not contracted with the health insurance plan to accepted negotiated rates. This mean that patients will typically pay more or the full amount for the service they receive.
What is the difference between OAP and PPO? ›
Cigna HealthcareSM* PPO plans are a large, national network similar to Open Access Plus (OAP) plans, but offers more choice with flexibility for out-of-network care. Our national network of Primary Care Providers (PCPs) and facilities makes it easy for employees to get access to care when needed.
What are 3 disadvantages of a network? ›
Disadvantages
- Purchasing the network cabling and file servers can be expensive.
- Managing a large network is complicated, requires training and a network manager usually needs to be employed.
- If the file server breaks down the files on the file server become inaccessible. ...
- Viruses.
One of the significant benefits of choosing in-network providers is cost savings. In-network providers have agreements with your health insurance company to offer services at discounted rates, which are pre-negotiated to be lower than what you might typically pay.
Which type of health organization will not help pay for doctors who are out of network? ›
A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency.
Why is it important to know if a doctor or medical facility is in network? ›
It's a good idea to check, since providers in the same network can charge different rates for the same services or prescription drugs, and since rates can vary depending on where you get care, like in a doctor's office versus a hospital.
Which is better a HMO or PPO? ›
HMO plans typically have lower monthly premiums. You can also expect to pay less out of pocket. PPOs tend to have higher monthly premiums in exchange for the flexibility to use providers both in and out of network without a referral. Out-of-pocket medical costs can also run higher with a PPO plan.
What happens if I see a doctor outside of my network? ›
If you choose to see a doctor who is outside the preferred network, you will generally have to pay a larger portion of the bill than you would for an in-network provider, but most plans will still cover a portion of the bill. With a PPO, you will have access to out-of-state providers that are considered in-network.
With a PPO, you can go to a doctor or hospital that is not on the preferred provider list. This is called going out-of-network. However, you pay more to go out-of-network. The PPO pays less or nothing at all.
What payment rules apply when the patient sees an out of network physician? ›
Beginning July 1, 2017, California law protects consumers from surprise medical bills when they get non-emergency services, go to an in-network health facility and receive care from an out-of-network provider without their consent.
What are 3 disadvantages of a PPO? ›
Disadvantages
- Higher monthly premium.
- Higher out of pocket expenses.
- Must monitor in-network vs out-of network to control cost.
A PPO plan provides more flexibility in choosing your health care providers, but it may cost more than an HMO. Key areas to remember: Your maximum copay or coinsurance is less when you stay in network for services. You can see a specialist and access many types of services without a referral.
Is Cigna HMO or PPO? ›
Our HMO and Network plans are offered by Cigna HealthCare of California, Inc.
Is it worth getting out of network coverage? ›
Provider Choice: Out-of-network coverage allows you to choose from a broader range of health care providers, including specialists who may not be available within your insurance network. If having the freedom to see specific doctors or specialists is a priority for you, out-of-network coverage can be valuable.
What happens if you see a doctor outside of your network? ›
If you see a provider outside of your HMO's network, they will not pay for those services (except in the case of emergency and urgent care). The doctors and other providers may be employees of the HMO or they may have contracts with the HMO.
What is an out of network coverage problem? ›
However, when you dial a mobile number, and it says "Out of Network Coverage Area", the phone is not reachable. This issue could be because any of the following reasons: Remote Use: The mobile number dialed might be in a remote area where there are no or less cell towers.
What is the likely result of using an out-of-network provider for routine health services? ›
You're likely to pay full price: Your insurer can't control what you'll pay for healthcare services without a contract with the out-of-network provider. This means you'll likely pay the full cost for the service, which is sure to be higher than a negotiated rate.
