Does my out of network expenditures count towards my in-network deductible?

Out of network expenses may or may not count towards in-network totals. This is something that we will see continue to change as plans look to further control healthcare expenses. Let’s look at the various possibilities.

Insurance carriers recommend how to design plans to those self insured groups with whom they work. For plans where they are fully insuring the members they make the decision on plan design. What this means is we can see within the same insurance carrier (who is listed on ID cards) different plan designs. The reason for this is how tightly the financially responsible party wants to control the healthcare expenses incurred.

Generally speaking fully insured plans are already or are moving towards a split between in and out of network expenses where one never helps cover any of the costs for the other. Thus, if you incur out of network expenses that are totally on top of in-network care you receive. What does this do to your out of pocket expenses?

Generally, out-of-network care limits are twice the in-network care cost limits. So if you use out of network providers extensively along with in network providers, it’s possible to end up spending three times or more your in network deductible before you are just on cost sharing. The total costs for out of network in some plans are quite high, so in the scenario where you are using both in and out of network providers you can really end up spending a lot more money than you planned to spend on healthcare for the year.

If you have a plan design not changed in a while it is possible your plan may still allow out of network care costs to count also towards in network deductibles. This is becoming more reare. When it does happen, if you hit the out of network deductible, you will also have met your, in-network deductible as well which helps keep the total costs in check for you.  These plans are rarer these days as healthcare costs continue to spiral out of control. Most plans do not work that way.

Most plans keep the in and out of network costs separate. It is all about making the cost difference between in and out of network care so significant there becomes a serious financial incentive to use in network provider. Part of it is the fact that out of network providers can collect any amount they want and insurance will only reimburse, or accept towards the deductible the amount they deem the “allowable.”  

Allowable levels are becoming better defined by the insurance carriers and communicated to the members. Often they are the same or only slightly more than is paid to an in-network provider. So the use of an out-of-network provider results in a portion of the cost going to the deductible while you may pay multiples of that amount for the actual care received. You also end up paying much more for that deductible as well. Overall going out of network these days will really cost you a pretty penny.