Understanding In-Network and Out-of-Network Benefits
Using in-network providers is key to receiving the highest level of healthcare benefits. Services from a provider other than an in-network one are considered out-of-network, except for emergency or urgent care away from home.
An exclusive provider plan, such as IU Health HDHP, does not cover out-of-network services other than emergency care and urgent care when away from home, certain children living outside Indiana, and services authorized by the plan in advance.
- Lower out-of-pocket costs (e.g., deductible and co-insurance).
- Deductibles, co-insurance, and out-of-pocket maximums are lower.
- The member is not responsible for charges above the plan’s allowed amounts.
- Preventive services are paid at 100%.
- Services requiring approval are authorized in advance.
- Higher out-of-pocket costs (e.g., deductible and co-insurance).
- Deductibles, co-insurance, and out-of-pocket maximums are higher.
- The member is responsible for charges above the plan’s allowed amounts, these changes can be significant.
- Preventive services are not paid at 100%.
- Out-of-network providers are not required to authorize services in advance. The member may have to request authorization or risk being responsible for charges.
- When emergency or urgent care services from out-of- network providers are covered with in-network deductibles and co-insurance, the member is responsible for charges above the allowed amount. These can be significant.