Risks and rewards of seeing an out-of-network provider
8 Minutes
Team Curative
Feb 10, 2025
When it comes to your health, choosing the right healthcare provider is crucial. Sometimes, you might find yourself contemplating whether to see an out-of-network (OON) provider. While this decision might seem challenging, understanding the risks and rewards can help you make a more informed choice, especially when managing the cost of healthcare through affordable health insurance.
In-network vs. out-of-network: why is there a cost difference?
Healthcare insurance plans distinguish between in-network and out-of-network providers. Your specific insurance plan establishes contracts with doctors, other practitioners, and various medical facilities. These are the providers in your “network.” Each provider has agreed to take your plan’s contracted rate as payment in full for services. The contracted rate includes the insurer’s portion of the cost and your own. Typically, the consumer’s portion of the cost is a copay, deductible, or coinsurance.
When you receive care from a provider or facility outside of your insurer’s network, you typically pay more for your care. OON providers have not set negotiated rates with your insurer, so their services may be costlier. In addition, many insurance plans require higher copays, deductibles, and coinsurance for OON care. Some may even require you to pay the total cost of the care you receive.
What is balance billing?
Balance billing occurs when an insurer pays an OON provider less than the provider charges for services. To make up the difference, the provider bills the patient for the remainder of the price.
“Surprise billing” refers to a type of balance billing where a patient receives care at an in-network facility, but an OON provider provides the care. Often, the patient is unaware that the provider is OON. Frequently, patients are dismayed to learn that they are responsible for the balance of their medical bills despite going to an in-network facility.
The rewards: why would I choose to see an OON provider?
Knowing the higher costs associated with OON providers, why would you choose to see one? Expanding your options to include OON providers typically makes finding care easier and can prevent delays. You’ll have more providers to choose from and may be able to avoid waitlists.
People may choose to see an OON provider for a variety of reasons:
They are comfortable with their OON provider and satisfied with the care they are receiving.
They require specialized treatment, but an appropriate specialist is not included in their health insurance plan’s network.
Changing providers would jeopardize their health. Despite the extra cost, it may be in a patient’s best interest to continue care with a particular OON provider.
They require medical care while traveling.
They switched health plans, and their provider is no longer in-network.
They live in a rural area. While the Affordable Care Act stipulates that in-network care must be available within a reasonable distance of a person’s home or workplace, these distances vary widely from state to state.
The risks: what are the drawbacks of receiving care from an OON provider?
If you choose to see an OON provider, costs and coverage can be unpredictable:
Insurance companies typically cover less of the cost of an OON provider. For example, your copay for an in-network provider may be $25, but it’s $35 for an OON.
Insurance companies do not usually reimburse patients based on the amount you paid your provider. Instead, they reimburse you for the “allowable amount” for the service you received. The allowable amount is the cost your insurer has decided is reasonable for a provider in your area to charge for a specific service.
Your plan’s deductible still applies to OON care. You will not be reimbursed for your care until you have met your yearly deductible.
In addition, receiving care at an OON facility or from an OON provider introduces the risk of fragmented care. Mistakes can happen when medical records are transferred between providers outside of your plan’s network. This can result in missing records, duplicate testing, and a lack of access to OON labs.
Curative: transparent coverage with a vast network of providers
Curative is a health plan employers and their talent love for its affordability, engagement, and simplicity. With $0 copays and deductibles, members can access preventive and timely healthcare with guided support. Imagine — a health plan that actually delivers better health — and sustainable savings.
How do Curative plans work?
Curative provides health coverage that supports its members in living their healthiest lives. All members are encouraged to attend a Baseline Visit with a Curative Care Navigator. During the visit, members work with their Care Navigator to tailor an individualized, preventive care plan and identify areas of opportunity and potential problems from the start of the plan.
This way, members better understand their plans and can access the right resources at the right time through our easy-to-navigate Provider Search. Curative plans provide comprehensive care with $0 copays, zero deductibles, and no out-of-pocket costs for all providers in the Provider Search, as long as it is for services listed in the benefits booklet.
How does Curative cover OON care?
Each of Curative’s three plans specifies if and how OON services are covered.
Curative’s Exclusive Provider Organization (EPO) Plan includes:
$0 copays and deductibles for covered services with any provider listed in our provider search
Access to personal Care Navigator
Wellness benefits, including preventive health services and chronic and acute care management
No out-of-network coverage, with exceptions for emergency services, certain facility-based providers, and services related to a network provider's services.
Curative’s Preferred Provider Organization (PPO) Plan includes:
$0 copays and deductibles for covered services with any provider listed in our provider search
$10,000/person and $20,000/family out-of-network deductible
$15,000/person and $30,000/family max out-of-pocket for out-of-network
Access to personal Care Navigator
Wellness benefits, including preventive health services and chronic and acute care management
Curative’s PPO Max includes all the benefits of the PPO Plan, makes OON care more affordable, and includes some extra coverage:
$0 copays and deductibles for covered services with any provider listed in our provider search
$0 copays and deductibles for out-of-network providers not listed on the Provider Search, with coverage up to a fair billable amount
$5,000/person and $10,000/family out-of-network deductible
$7,500/person and $15,000/family max out-of-pocket for out-of-network
Access to personal Care Navigator
Wellness benefits, including preventive health services and chronic and acute care management
Members experience expanded coverage to national pharmacy chains like Walgreens, CVS, and Walmart.
Access to ClassPass and chiropractic coverage (up to 20 visits per year)
In addition, Curative covers balance billing for providers included in Curative’s provider search.
With each of these plans, members also have the option of using the Curative Zero Card. While the Curative Member ID Card covers in-network providers, the unique-to-Curative Zero Card is a payment card that expands access to providers and serves as a backup if the provider does not take the Curative Member ID Card. If a provider is not listed on the Provider Search, Curative members can nominate a provider to be added as a Curative Zero Card provider. The payment options expand provider options and reduce barriers to getting care when and where members need it.
Learn more today about how Curative’s affordable health insurance options can support your health goals.
Every Curative member can continue to qualify for the $0 deductible or copay for covered services from providers listed on Provider Search and preferred prescriptions by completing a Baseline Visit in the first 120 days of the plan’s effective date.
To see all disclaimers, please view them here.
Resources
In-network and out-of-network care (2024). FAIR Health Consumer.
https://www.fairhealthconsumer.org/insurance-basics/healthcare/in-network-and-out-of-network-care
Kona, M. (5 Febuary 2021). State Balance-Billing Protections. The Commonwealth Fund. https://www.commonwealthfund.org/node/27021
Montgomery, Kelly. (2 June 2024). What an Out-of-network Provider Means. Verywell Health.
Sheldon-Dean, Hannah. (2 Oct 2024). Understanding Out-of-network Benefits. The Child Mind Institute.
https://childmind.org/article/understanding-out-of-network-benefits/
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Table of Contents
In-network vs. out-of-network: why is there a cost difference?
What is balance billing?
The rewards: why would I choose to see an OON provider?
The risks: what are the drawbacks of receiving care from an OON provider?
Curative: transparent coverage with a vast network of providers
Resources
