PAF has compiled disaster resources for those whose medical care and homes are impacted by natural disasters, including recent Hurricanes Michael, Florence and Lane and western wildfires. Search "Disaster Resources" in the National Financial Resource Directory by clicking here. ✕
A national 501 (c)(3) non-profit charity that provides direct services to patients with chronic, life threatening and debilitating diseases to help access care and treatment recommended by their doctor.
Going out of network means you’re seeing a provider who doesn’t have an agreement in place with your insurance company for payment terms. Some health plans, like HMOs or EPOs, do not reimburse out-of-network providers at all. This means that with these plans, you could be responsible for the full amount charged by your doctor if you choose to go out-of-network for care.
HMO: Health Maintenance Organization
These plans require you to choose a primary care physician who will refer you for care to the specialized providers that are within your network.
EPO: Exclusive Provider Organization
These plans do not require you to choose a primary care physician or obtain a referral to see a specialist but often have a very limited network of providers, and there is no out-of-network benefit.
PPO: Preferred Provider Organizations
These plans have a network of providers, but they will still pay towards out-of-network care, but at a lower rate. You do not need a referral to go to a specialist under this plan.
POS: Point of Service
These plans resemble HMOs but are less restrictive because you can get coverage for out-of-network care in certain circumstances. But, like HMOs, most POS plans require you to get a referral from your primary care physician for specialized care.
Here’s an example of how the same plan may pay for in-network and out-of-network care:
There may be times when using an out-of-network provider is your best option:
Emergencies: In an emergency situation, you must go to the hospital or urgent care facility that is closest to you. Most plans will make an exception for out-of-network care in the case of a true emergency. It’s important to that you or a loved one contact your insurance company as soon as possible in the event of an urgent situation and inform them that you had to seek out-of-network care.
Distance Issues: If you live in a rural area and there is no network specialist close by, you may need to utilize an out-of-network doctor. Contact your insurance company if this is the case and they may be able to negotiate with a non-participating doctor for your care. In these cases, many health plans will cover the cost at an in-network rate.
Specialist Care: If you have a rare condition, specialists can be limited, so out-of-network care may be your only option. Or if your treating specialist leaves your insurance network, you may choose to continue that care by going out-of-network. Depending on your plan, you may need to appeal for continued in-network coverage, if only for a period of time or a set number of visits.
Out-of-Town Care: If you need medical care while away from home, you may have to visit a doctor not connected with your plan. If it’s not an emergency, it’s a good idea to call your health plan first to find out if there are any in-network doctors in the area. Sometimes insurers handle your visit to a non-participating provider as if it were in network.
This information is part of the “It Matters Empowerment Pathways” content series developed as part of the Matters of the Heart project.