Estimating Out-of-Network Care Costs

HMO & EPO Plans:

If you have an HMO or EPO plan, then your plan generally does not cover out-of-network benefits, except for emergency services. If you still want to receive non-emergency services from an out-of-network provider, it’s a good idea to know how much the services will cost. Ask the provider how much he or she charges for any service(s) you will be receiving.

If you cannot get this information from your provider, you can use the Fair Health Calculator to get an estimate of the Usual, Customary and Reasonable (UCR) rate for services from an out-of-network provider in a given geographic region, based on average health care costs across New York State. Your provider may actually charge you more or less than the UCR rate.

PPO & POS Plans:

If you have a PPO or POS plan, then your plan generally does provide benefits for most covered services received from out-of-network providers. The terms and conditions of out-of-network coverage vary depending on the specific plan you have. Beacon Health Options offers tools to help you estimate our payment and your out-of pocket costs for out-of network services. There are two steps to estimating how much you are likely to pay for an out-of-network service:

  1. Identify the provider’s charges for an out-of-network service. Before receiving services from an out-of-network provider, ask that provider how much he or she charges for any service(s) you know you will be receiving. If you cannot get this information, you can use the Fair Health Calculator to get an estimate of the approximate dollar amount the out-of-network provider will charge you for the service(s). Note that you will need to have the procedure code(s) and certain other information about the services to use the calculator. This Calculator provides the Usual, Customary and Reasonable (UCR) rate for services from an out-of-network provider in a given geographic region, based on average health care costs across New York State. Your provider may actually charge you more or less than the UCR rate.
  2. Determine the difference between the Beacon Health Options’ allowance and the charges of the out-of-network provider. You will be responsible for the difference between Beacon Health Options’ allowance (maximum amount we pay for a service) and charge(s) from the out-of-network provider, as well as for any out-of-network cost-sharing that applies to the service under the terms of your plan. To identify Beacon Health Options’ allowance for a specific service, please contact the phone number for behavioral health (mental health/substance use) on your ID card.

Note: Beacon Health Options’ allowance will generally not reflect any applicable cost-sharing (i.e., copayment, deductible and/or coinsurance), which you must also pay toward the service(s) and will reduce the amount of the allowance actually payable by Beacon Health Options See your member contract or certificate of coverage for the cost-sharing that applies under your plan. Benefits will be subject to all terms, conditions, limitations and exclusions set forth in your plan. Benefit estimates are not a guarantee. The actual payment will depend on a number of factors, including, for example, the services you receive, the amount billed by your physician or other provider, the actual procedure codes submitted and your eligibility for benefits at the time you receive services