10 / 10
Your plan this year
Premium$400 / month
Deductible$2,000
Primary care copay$30
Coinsurance20%
Out-of-pocket max$6,000
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Situation 10 · Out of network
You choose to see a specialist who is not in your plan’s network. It is not an emergency. Your plan is a PPO. The specialist charges $900.
Which numbers on the card apply?
Correct!
Not quite.
The five numbers describe in-network care. A PPO has a second set for out-of-network providers: usually a separate, larger deductible, higher coinsurance and a higher out-of-pocket maximum. The plan also pays based on its own allowed amount, and the specialist can bill you for the difference between that and the $900 charge. That difference does not count toward any maximum. With an HMO or EPO, the plan would usually pay nothing.
More: Your Doctor Is “In-Network.” So Why Is Your Medical Bill Still So High?