Working with Doctors
Your plan allows you to see doctors from our nationwide network of preferred providers. Unlike HMO plans, you don't need to get referrals for specialist services or choose a PCP. However, it's highly recommended that you choose a PCP in order to better coordinate your care.
Another benefit of choosing a PPO plan is that you are covered for out-of-network care. However, in most cases, you'll pay more for care from providers outside your network than from preferred providers in your network.
Find a Doctor & Estimate Costs
Find care and save money with one simple tool. Our Find a Doctor & Estimate Costs tool makes it easy for you to find what you need. Search for doctors, dentists, and hospitals, and get cost estimates for over 1,600 procedures. Plus, the ability to read and write reviews, and compare up to ten doctors at a time puts more control in your hands.
Choose In-Network Providers and Reduce Your Costs
When your plan renews on or after January 1, 2012, we will begin paying out-of-network health care providers for your covered services based on a "usual and customary" fee schedule, instead of the health care provider's actual charges.
What this change means for you
You would be responsible for the difference between what your out-of-network health care provider actually charges for care and what is allowed under our usual and customary fee schedule. This would be in addition to any copayments, deductible, and co-insurance that apply to your care. This means you would likely pay more when you get covered care outside your PPO network after your plan renews since out-of-network providers can charge as much as three to five times more than in network providers for the same services.
This could mean a significant increase to your out-of-pocket costs for care you receive from an out-of-network provider.
This change does not apply to emergency medical care. You are always covered at the in-network level in an emergency.
Let's Look at Some Examples
All dollar amounts are not actual charges and are hypothetical and for illustrative purposes only.
Example A: Office Visit
|
Cost Type |
In-Network Provider |
Out-Network Provider1 |
|---|---|---|
|
Health care provider's charge |
$500 |
$500 |
|
Blue Cross Blue Shield pays |
Negotiated rate |
Usual and customary fee = $225 |
|
Your Copayment |
$20 | $0 |
|
Your Co-insurance (after deductible) |
$0 |
20% of $225 = $45 |
|
Your balance bill |
$0 |
$500 - $225 = $275 |
|
Your total out-of-pocket cost (after deductible) |
$20 |
$45 + $275 = $320 |
Example B: Surgery
|
Cost Type |
In-Network Provider |
Out-Network Provider1 |
|---|---|---|
|
Health care provider's charge |
$90,000 |
$90,000 |
|
Blue Cross Blue Shield pays |
Negotiated rate |
Usual and customary fee = $40,500 |
|
Your Copayment |
$500 (hospital copayment) | $0 |
|
Your Co-insurance (after deductible) |
$0 |
20% of $40,500 = $8,100 |
|
Your balance bill |
$0 |
$90,000 - $40,500 = $49,500 |
|
Your total out-of-pocket cost (after deductible) |
$500 |
$8,100 + $49,500 = $57,600 |
Example A: Office Visit
In-Network Provider
|
Health care provider's charge $500 |
|
Blue Cross Blue Shield pays Negotiated rate |
|
Your Copayment $20 |
|
Your Co-insurance (after deductible) $0 |
|
Your balance bill $0 |
|
Your total out-of-pocket cost (after deductible) $20 |
Out-Network Provider1
|
Health care provider's charge $500 |
|
Blue Cross Blue Shield pays Usual and customary fee = $225 |
|
Your Copayment $0 |
|
Your Co-insurance (after deductible) 20% of $225 = $45 |
|
Your balance bill $500 - $225 = $275 |
|
Your total out-of-pocket cost (after deductible) $45 + $275 = $320 |
Example B: Surgery
In-Network Provider
|
Health care provider's charge $90,000 |
|
Blue Cross Blue Shield pays Negotiated rate |
|
Your Copayment $500 (hospital copayment) |
|
Your Co-insurance (after deductible) $0 |
|
Your balance bill $0 |
|
Your total out-of-pocket cost (after deductible) $500 |
Out-Network Provider1
|
Health care provider's charge $90,000 |
|
Blue Cross Blue Shield pays Usual and customary fee = $40,500 |
|
Your Copayment $0 |
|
Your Co-insurance (after deductible) 20% of $40,500 = $8,100 |
|
Your balance bill $90,000 - $40,500 = $49,500 |
|
Your total out-of-pocket cost (after deductible) $8,100 + $49,500 = $57,600 |
1. After the member has met his or her deductible.
What you can do
The easiest way to avoid these additional costs is to find an in-network health care provider within the Blue Cross Blue Shield national PPO network. Since you have a PPO plan, you can see any in-network health care provider across the nation without a referral.
You can find an in-network health care provider using our Find a Doctor search.
Hospital Choice Cost Sharing
If your plan includes Hospital Choice Cost Sharing, what you pay for certain services depends on the hospital where you choose to get care. Our Hospital Choice Cost Sharing page can help you understand the your costs and care options.