Reference Guide


	In-Network vs. Out-of-Network Costs Comparison

This example outlines how much a hospital stay could cost and how much you would pay under two scenarios when you have a PPO plan: with services from network providers and services from out-of-network providers.

	In-Network Hospital (Plan pays 80%)	Out-of-Network Hospital (Plan pays 60%)
Actual hospital charge:	$22,000	$22,000
Amount recognized by medical plan:	$14,000 (the discounted rate for health plan)	$14,000 Plan does not recognize the $8,000 difference
Medical plan pays:	80% of discounted rate: $14,000 x 80% = $11,200	$14,000 x 60% = $8,400
Member pays:	20% of the discounted rate: $14,000 x 20% = $2,800	40% of charges ($14,000) plus 100% of the amount the plan does not recognize ($8,000): $5,600 + $8,000 = $13,600

Source: California Department of Managed Health Care