For many, health insurance is a way to make health care affordable. Typically, it is offered by employers through a private or public plan. Medi-Cal is California's Medicaid program, which provides free or low-cost medical services to children and adults with limited incomes. Federal and state taxes support it.
Health insurance companies can charge you more for out-of-network services when they don't have a contract with the provider or facility. You can avoid these surprises by educating yourself about your plan's limitations and additional payment options.
Some plans require that out-of-network providers give you an easy-to-understand notice explaining that getting care could be more expensive and your options to avoid balance bills. You're only required to sign this notice or get care out-of-network if you consent to it by signing a form called an assignment of benefits.
A health insurance company can calculate the cost of out-of-network medical care using data from a database. These databases include the Prevailing Healthcare Charges System (PHCS) and Medical Data Research (MDR).
The amount a health insurance company pays for a service to an out-of-network provider is generally less than what the provider charges for that service. This difference is known as the "qualified payment amount."
Medi-Cal insurance will cover emergency services when needed without prior authorization or preauthorization. But you should always check with your insurance provider to see if your out-of-network emergency services are covered before going to an out-of-network facility or provider.
Insurance Law SS 3241(c) requires health plans that issue comprehensive group policies that cover out-of-network ("OON") services to provide at least one substitute option for OON coverage using the 80th percentile of charges for a particular service, also known as the UCR. The UCR is derived using data from a benchmarking database maintained by a nonprofit organization designated by the Superintendent of Financial Services, which includes the 80th percentile of costs for standardized health care services offered.
Health insurance deductibles are the amount you must pay before your health insurance plan covers most medical services. Once you meet your deductible, your health insurance plan pays the rest of your costs for that year. Deductibles can vary from plan to plan, so it's essential to read the fine print before you sign up for a program. Also, compare deductibles and copay/coinsurance amounts between different plans.
Often, individual & family health insurance plans feature a deductible structure where the insurance only pays for services once you meet your deductible. Alternatively, your plan may pay for some healthcare services before you complete your deductible while exempting others.
Some plans even have a separate deductible for when you visit medical providers outside of the plan's network. Typically, these deductibles are lower than the plan's overall deductible.
For citizens of California who are underinsured, have impairments or medical problems, and are not eligible for alternative health coverage, there is a public health insurance program called Medi-Cal. Medi-Cal can be used as secondary coverage to help pay for some expenses that primary health insurance doesn't cover, such as doctor visits, hospital stays, prescription drugs and rehabilitation. Whether you have Medi-Cal as primary or secondary coverage, it's essential to know the rules of your specific plan.
Copayments are a common way that health insurance companies split the costs of medical services and prescriptions between you and your insurer. They can range from small amounts to a large number of dollars depending on the type of service and whether you have a deductible or coinsurance.
Copays can be a significant factor in how much you pay for health care each month, so it is essential to know what they are and their effect on your budget. Generally, you have a lower copayment for standard medical care, like doctor visits and urgent care, than for specialty or emergency room visits.
You also have a lower copayment for drugs than for medical procedures and generic medications versus name brands. However, some variations between HMO and PPO plans may impact your monthly healthcare costs.
In-network refers to the health care providers and facilities with which your insurance company has a contract. Choosing in-network care can help lower your costs.
For services that are covered by your plan, you will receive maximum benefits if they are received at in-network hospitals and ambulatory surgical centers. These include emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist and intensivist services, as well as some wellness activities.
However, you could have to pay more if you utilize these services while covered by out-of-network benefits. These costs are called surprise bills.
You are protected from surprise bills when you visit an in-network hospital or ambulatory surgery center. These protections are increasing and will now cover all providers, not just doctors.
If you get other services at these in-network facilities, these providers can only balance bill you if you give written consent and give up your protections. These protections don't apply to out-of-network emergency services in hospitals, air ambulance services or non-participating physicians.
You can contact your health insurance for a referral or preapproval to enable the service at an in-network fee if you need to see a doctor not in our network. This process varies from insurer to insurer. It is best to work out these details with your health insurer before the service occurs. You can find more information about this process from your health insurer's website, plan documents or customer service representatives.