The short answer is you can, but you’ll be sorry unless you take a few steps first.
The basic idea with a PPO is that you have a “network” of physicians, hospitals, imaging centers, pharmacies and many other ancillary medical facilities that have banded together. They have each contracted with the various Texas health insurance carriers as a simple business arrangement: this medical network agrees to give members of the PPO (you) contracted rates in exchange for the insurance carrier sending them patients by placing those practitioners in the network.
For example, when you visit a physician that is “in-network”, you will generally just pay a co pay for the visit (if your plan has doctor co pays) or the PPO contracted rate. If you have a co pay, the amount you spend will generally not count toward your deductible. If you plan doesn’t have co pays, the allowed amount by the insurance carrier that you spend on the visit will generally count toward your major medical deductible. The idea here is that if you stay in network, you’re receiving a rate (either through a co pay or through the PPO contracted rate) that would generally be lower than what you would pay if you didn’t have your Texas health insurance policy.
If you do visit a doctor or hospital that is “out of network” on your plan, make sure to do this very sparingly. You’ll end up paying whatever they want to charge and the amount you spend will count toward your “out of network” deductible.
Here in lies the problem: Out of network deductibles are generally double what the in network deductible is. Also, your out of pocket costs beyond the out of network deductible will generally be higher as well.
For example, if you have a surgery and use an out of network hospital, but an in network surgeon and anesthesiologist, you end up paying much more than if the hospital was in network.
Let’s say you have a $5,000 in network deductible with 100% coverage thereafter (i.e. the Texas BCBS HSA Plan VIII). The out of network deductible on this plan is $10,000. If your surgical and anesthesiology costs total $4,800, but your hospital costs total $3,500, you’re going to pay the entire amount of $8,300. If the hospital were in network, your total out of pocket would only be $5,000. Why? The $3,500 hospital cost counts toward the $10,000 out of network deductible and does not go against the $5,000 in network deductible.
The bottom line is that if you have a PPO plan, make sure to stay in network with everyone who lays a hand on you. Demand that your surgeon uses only in-network assistants, anesthesiologists, imaging centers and of course, that the surgical center or hospital is also in network. You’ll be sorry if you don’t.
If you have questions about who is and is not in your network, please visit us at http://selectedben.wpengine.com or call 866.270.6209.