In-Network vs. Out-of-Network Costs Comparison
Here are some comparisons of how much you’ll pay with various plans from an in-network provider versus an out-of-network provider. Say you visit a provider who usually charges $1,000 for a service. But, that provider is in your plan’s network. That means they have agreed to accept your insurer’s contracted rate – say, $500 – rather than the amount they normally charge. How much will you have to pay?
| 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) |
$14,000Plan 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 |