Navigating Out-of-Network
An out-of-network provider does not have a contract with your insurance company. If a provider tells you that they do not take your insurance, you may still be able to use out-of-network benefits to pay for care with them.
When your child gets care from an out-of-network provider, you pay the entire cost of the session upfront. Then, you file a claim with your insurance company, and they reimburse you for some of the money you spent. Filing a claim means filling out paperwork about the care your child received and sending it to the insurance company, usually by mail. Your provider will give you a document called a superbill to include with your claim. A superbill shows the company exactly what kind of care you or your child received.
There are several factors to consider when looking at the cost of out-of-network care:
Insurance companies usually cover less of the cost of an out-of-network provider. For example, you might have to pay a $25 copay if you see an in-network provider but a $35 copay if you see an out-of-network provider.
Insurance companies do not usually reimburse you based on the amount you actually paid your provider. Instead, they reimburse you based on what’s called the allowable amount for the service your child received. The allowable amount is the amount that your provider has decided is reasonable for a provider in your area to charge for a specific service. For example, your insurance company’s allowable amount for one individual psychotherapy session may be $100. If your child’s therapist charges you $125 for that session, your insurance company will still reimburse you as if the cost were $100.
The deductible still applies for out-of-network care. You will not be reimbursed for your child’s care until your deductible for the year has been met.
The downside is that getting care using out-of-network benefits is almost always more expensive. You must pay for sessions up front, and getting reimbursed by your insurance company can be complicated and time-consuming.
It’s also common for insurance companies to reject claims for out-of-network benefits, even if the care should be covered under your plan. The most common reasons that claims are rejected are small errors like misspelled names or wrong birthdates. If you do use out-of-network benefits, be sure to check all the details on your claims carefully.
