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One of the questions policyholders ask the most frequently about their health insurance is whether they can visit an out-of-network provider. Irrespective of the type of policy you have, you can always see any provider you wish; it’s just a matter of how much your insurer will reimburse you for the visit. The level of reimbursement for out-of-network care varies widely among different health insurance plans, with some policies not offering any coverage. In this post, we’ll address the various levels of reimbursement for out-of-network care provided by the most popular types of health insurance.

HMO Policies

Opting for an HMO
policy is an effective way to minimize your health insurance premiums, but these types of plans typically offer the least amount of flexibility in terms of provider selection. Traditionally, HMOs do not provide coverage for non-network care. Even if you have a referral to see a specialist, you must still stay within the confines of the HMO’s provider network. If you choose an out-of-network provider, you will have to pay all or most of the cost out of pocket.

PPO Policies

PPO plans allow members more choice and flexibility in their provider selections. If you see an out-of-network provider on a PPO plan, you will receive some reimbursement for the services, but not as much as if you had stayed in network. Out-of-network visits usually have higher co-insurance or co-pays in order to compensate the insurer for the non-network physician’s higher prices. With a PPO, you do not have to have a referral to see a specialist, whether in or out of network. Furthermore, with some policies, you might have to pay for non-network care out of pocket and then submit the bill to your insurer for partial reimbursement.

POS Policies

If you have a POS policy, you will have to pay for out-of-network care yourself unless your primary care physician (PCP) specifically provides you a referral to a non-network physician. When you have a referral from your PCP for an out-of-network provider, the POS policy will reimburse you for the visit at the same rate they would for in-network care. In this way, a POS plan is like a mix between an HMO and a PPO.

Indemnity Plans

Traditional health insurance, or an indemnity plan, allows you to visit any provider you wish while still receiving the same rate of reimbursement. Indemnity plans do not have networks wherein they have negotiated lower rates with certain providers, so policyholders have a great degree of freedom in provider selection. Usually, regardless of the provider you visit, you will be reimbursed for 80% of the costs with an indemnity plan.

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