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Health plans have a specific group of doctors, dentists, pharmacies, hospitals, and other healthcare providers you can use at a contracted, in-network price. This is known as your network. Your network name is on your ID card in the app.
Since you pay for part of the costs of your medical care, it's important to know that you will almost always pay less with an in-network provider compared to an out-of-network provider. Services from out-of-network providers may cost more, or may not be covered at all by your plan.
There are no limits or controls on the charges out-of-network providers can bill, so you may receive much higher bills than you expect. In-network providers contract with Premera and charge lower rates that are set for services and procedures. We call these allowed amounts.
Your plan only contributes to allowed amounts. So, if you have a procedure with an in-network provider who usually charges $200, but the allowed amount is $150, they can only charge $150. If you have the same procedure with an out-of-network provider, the provider can bill you a higher amount. If your plan pays 60 percent for out-of-network services, that’s only 60 percent of the allowed amount. The 40 percent of the allowed amount (your coinsurance) and anything over that would be your responsibility. This is called balance billing.
It depends. Some plans have no out of network coverage at all. Other plans have separate in-network and out-of-network deductibles and out-of-pocket maximums. Your safest bet to save money is to only use in-network providers and services. To get specifics on what your plan covers and what you’ll pay, sign in and check your benefit details.
Sometimes, yes. If your provider orders services and products including lab work, durable medical equipment (wheel chairs, orthotics, and braces), CPAP (breathing machines), referrals to specialists, radiology (x-rays, CAT scans, and MRIs), or physical therapy, be sure to request that they order from providers that are in network. The savings to you could be considerable.
Lab work is the most common cause of unexpected costs. Ask your healthcare provider these questions to avoid paying more.
Is everything ordered covered by my plan?Sometimes doctors will order lab panels (several tests in a set). Review the lab order with your healthcare provider to confirm that each panel and test is covered.
What lab will this go to?You can use the Premera app to confirm that the lab you or your samples are sent to is in network. If the lab isn’t in network, ask the doctor if you can have the work done at an in-network lab.
If you don’t have the app, you can also check labs by signing into your web account and using Find a Doctor. Search by lab name and if it doesn’t appear in the list, it’s not in your plan network.
Where will the lab work be done?If you’re sent to a lab, ask if they send anything to another location for processing. If they do, check your app and make sure that lab is in network.
Same-state care and labsYou might not realize that getting a lab order from a doctor in one state and having the labs done in another state can cost you more because of claims processing rules. Get both from the same state to avoid extra costs.