If you currently have an Ohio health insurance policy, then you probably pay a “copay” on your office visit coverage. The “copay” is the dollar amount you must pay for your visit to the doctor. Normally, copays range from $15-$40. Sometimes they’re as much as $50. And if you have a deductible that applies, you pay almost the entire amount.
If your doctor does not participate in your plan, your out-of-pocket expense will be higher. A lot higher. That’s because your insurer (probably Anthem, UnitedHealthOne or Medical Mutual) will not (and can not) contractually force the provider to charge a lower rate. And that difference can be substantial.
Verify Your Provider
So what can you do? Perhaps your best course of action is to ensure that when you are treated for a sickness or an illness, you have previously verified that your doctor (or Urgent Care facility) is considered “in-network.” It will likely mean the difference of paying about $30 vs. perhaps paying more than $100. A specialist visit will result in greater savings. An unexpected emergency room visit could be extremely expensive if you go outside of your plan.
Perhaps the biggest price difference are ER or hospital bills. If you do not use a network provider, the difference in your actual bill could easily be thousands of dollars (or more). If you are scheduling a surgery, there should be ample time to determine the status of the hospital. You can also call them directly or easily view online a provider list from your carrier. It’s common that you can use out-of-state facilities, as long as network-verification occurs before treatment.
What About An Emergency?
If your treatment is an emergency and life-threatening, typically it will not matter where you are treated. It will be considered an “in-network” expense. For example, if you live in Toledo, and are vacationing in Florida, let’s assume you suddenly have an appendicitis attack. Of course, your vacation is ruined, but that’s a minor point!
If/when you are rushed by ambulance to the hospital, naturally, you don’t have time to research where you are going to be taken and what providers the facility accepts. You’re probably going to have your surgery at the closest hospital or trauma center. And that’s precisely the proper procedure.
Your entire stay, including, surgery, room and board, anesthesia, doctors visits and consultations etc…should be classified as a network visit by your health insurer in Ohio. As a result, regardless whether you have a high-deductible plan or a PPO with little or no deductible, you should not be subject to a higher cost for going “outside” of the provider network. You can also verify this procedure with your carrier.
The type of coverage you have, whether it is a group, individual, catastrophic or comprehensive, will still cost you less when you utilize your provider list. If you have an HSA for 2013 or later, the same set of rules apply.
Yes, the size of the insurer will often have a direct correlation on the number of providers you will have access to. For example, as you might expect, Anthem and UnitedHealthcare have the largest number of physician, specialist and hospital options in the state. Medical Mutual and Aetna aren’t far behind and Humana still maintains many participants. Kaiser and Summa Health are regional carriers and focus more on the Northern portion of the state.