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Cost of Out-of-Network Doctors & Hospitals

Legal Notices: Health benefits and health insurance plans contain exclusions and limitations.

People are paying more of their healthcare costs these days.  It’s no wonder there is a lot of interest in keeping these costs down.

A smart way to do this is to stay in network.  We negotiate rates with providers to help you save money. We refer to these providers (such as doctors, hospitals, and surgical centers) as being “in our network.” 

There may be times when you decide to visit a doctor or hospital not in the network.  Some plans cover out-of-network care only in an emergency – otherwise, you are responsible for the full billed amount. For plans that do cover out-of-network care, you’ll usually pay more than if you stayed in the network.  

See how much less it can cost to stay in network

Some plans do not offer any out-of-network benefits. For those plans, out-of-network care is covered only in an emergency.  Otherwise, you are responsible for the full billed amount of any care you receive out of network.

The information on this page is for plans that offer both in-network and out-of-network coverage.

These plans pay for out-of-network services based on an “allowed” amount.  Most Banner|Aetna plans determine the allowed amount based on what Medicare would pay, or on a “reasonable” amount. Your plan documents will tell you how your plan determines the allowed amount.

We will use an example to show you how out of pocket costs are calculated if you stay in network and if you go out of network for the same care.

Let’s look at an $825 charge from a doctor’s visit.

In network, your cost for this visit is $140. Out of network, it’s $645 – so you pay an extra $505.  Here’s why:

Cost of Out-of-Network Doctors and Hospitals Table

IN NETWORK

OUT OF NETWORK

The doctor bill is $825. For doctors in our network, we’ve contracted a price of $500 for this type of visit. This is all the doctor can collect. So you get a $325 discount at the start.


Your cost so far: $0

The doctor bill is $825. The out-of-network “allowed” amount for this type of visit is $400. The doctor can look to you to pay the rest – in this case $425.  That amount is your responsibility and is called balance billing.

Your cost so far: $425

You pay your deductible for in-network care, which is $50.

$500 - $50 leaves $450.


 

Your cost so far: $50 ($0 + $50)

You pay your deductible for out-of-network care, which is $100.

Deductibles for out-of-network care are usually higher than for in-network care.

$400 - $100 leaves $300.

Your cost so far: $525 ($425 + $100)

Now that you’ve met your deductible, your plan pays 80% of the rest. In this case, that’s $450.  Your plan pays $360 (80% of $450).


You pay the other 20%, or $90. We call this your coinsurance.

 



Your total cost: $140 ($0 + $50 + $90)

Now that you’ve met your deductible, your plan pays 60% of the remaining allowed amount.  In this case, that’s $300.  Your plan pays $180 (60% of $300).

You pay the other 40%, or $120. We call this your coinsurance.

We pay a smaller percentage for out-of-network care than for in-network care. That means your coinsurance (the percentage you pay) is higher.

Your total cost: $645 ($425 + $100 + $120)

How does going out of network affect out-of-pocket limits?

An out-of-network doctor can charge any amount he or she wants. He has not agreed to a contract price for the covered service. In this case, the doctor is charging $825. Not all of that money counts toward your out-of-pocket limit.

  • Your out-of-network deductible ($100) counts toward your out-of-pocket limit.
  • Your coinsurance ($120) counts toward your out-of-pocket limit.
  • The extra amount the doctor can bill ($425) does not count toward your out-of-pocket limit. 

How to lower your costs

Ask your doctor to refer you to a specialist, hospital or surgical center that accepts your plan.

Or search our provider directory

Find out what it will cost before you go. Ask your out-of-network providers what the billed amount will be. For in-network care, your secure member website may be able to provide rate estimates. Or talk with the in-network provider’s office about what you may be asked to pay.

Does your member ID card have “NAP” on the front? That stands for National Advantage™ Program. And it has benefits for you:

  • You can get discounts for out-of-network care from NAP providers. Your out-of-pocket costs may be less than your costs for seeing other providers who are out of network.
  • If you get care from a NAP provider, you won’t get a balance bill.  You will pay your usual cost sharing for out-of-network care.

Check your most recent ID card to see whether your plan has the program. Some plans that used to have NAP no longer have it.

Transforming health care, together

Banner|Aetna aims to offer access to more efficient and effective member care at a more affordable cost. We join the right medical professionals with the right technology, so members benefit from quality, personalized health care designed to help them reach their health ambitions.

Contact us

Health benefits and health insurance plans are offered, underwritten, and/or administered by Banner Health and Aetna Health Insurance Company and/or Banner Health and Aetna Health Plan Inc. (Banner|Aetna). Banner|Aetna is an affiliate of Banner Health and of Aetna Life Insurance Company and its affiliates (Aetna). Each insurer has sole financial responsibility for its own products. Aetna and Banner Health provide certain management services to Banner|Aetna. Aetna, CVS Pharmacy® and MinuteClinic, LLC (which either operates or provides certain management support services to MinuteClinic-branded walk-in clinics) are part of the CVS Health® family of companies.

On-Demand Virtual Care with 98point6 by Transcarent

Banner|Aetna offers access to 98point6 by Transcarent, a virtual care solution that enables members to connect to care anytime, anywhere via secure in-app messaging.

Treatment is provided by a U.S.-based care team, including board-certified doctors, who can diagnose and treat over 1,000 conditions, outline care options, prescribe* medication, and order labs or imaging when appropriate—all through the convenience of a mobile app.

Key Features:

  • Audio, video, and Spanish translation support available as needed
  • Access to care plans and lab results directly within the app
  • Referrals to in-network resources and specialists
  • Care is available in all 50 states and Washington D.C.
  • 24/7/365 access with an average wait time of under 2 minutes—no appointment required.

Available to enrolled Banner|Aetna members and covered dependents age 1+* in an eligible plan.

Cost: Low-to-no-cost per visit*, depending on plan details.

*FOR ENROLLED MEMBERS AND COVERED DEPENDENTS AGE 1+: 98point6 by Transcarent is available to members age 1-17 when an adult parent or guardian is also enrolled in the plan. Access to 98point6 by Transcarent is not included in all plans.

*FOR LOW-TO-NO-COST WITH 98POINT6 BY TRANSCARENT: Members enrolled in a health savings account (HSA) or qualified high-deductible health plan (HDHP) must pay the applicable cost-share for virtual care visit until their deductible is met, after which services will be provided at no cost-share. All other health plan members pay $0 per virtual care visit regardless of whether their deductible has been met. Please refer to your plan documents for your applicable cost-share amounts.

*FOR 98POINT6 BY TRANSCARENT PRESCRIBING: 98point6 by Transcarent providers do not prescribe controlled substances (such as opioids), lifestyle medications (such as Viagra and Propecia) or weight loss medications (Wegovy or Ozempic). 98point6 by Transcarent and Transcarent Clinic clinicians are independent contractors and are neither agents nor employees of Banner|Aetna or plans administered by Banner|Aetna, and does not guarantee that a prescription will be written. Transcarent Clinic providers will not prescribe DEA-controlled substances, non-therapeutic drugs and certain other drugs that may be harmful because of their potential for abuse. Clinicians reserve the right to deny care for potential misuse of services

This material is for information only. An application must be completed to obtain coverage. Rates and benefits vary by location. Providers are independent contractors and are not agents of Banner|Aetna. Provider participation may change without notice.

Health insurance plans contain exclusions and limitations.