Out of Network vs Non Participating Provider and Out of Pocket Maximums

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So, I’m currently shopping for a Blue Cross Blue Shield Insurance Plan for Illinois during open enrollment for 2021 on their website. I’m deciding between the Silver 303 and Gold PPO 204 plans (leaning towards the silver) and one of the things that seemed concerning was the individual out of pocket maximums (they are identical for both plans).

PPO Silver 303: https://www.bcbsil.com/ooc/ind/ooc-spsh41bceiilo-il-2021.pdf
PPO Gold 204: https://www.bcbsil.com/ooc/ind/ooc-gpsh30bceiilo-il-2021.pdf

Individual Out of Pocket Expense Limit for Participating Provider: 8,550
Individual Out of Pocket Expense Limit for Non-Participating Provider: Unlimited

At first glance, it seems like if I go out network, I won’t have an out of pocket maximum since it’s unlimited. So I called customer service and they said the following:

I can go out of network and that would count towards my 8,550 out of pocket max if they accept my PPO.

This was slightly confusing because doesn’t out of network imply that it is not a participating provider? What’s the difference between a participating provider and non participating provider? In network and out of network?

Additionally, because of the unlimited out of pocket expense for non-participating providers, I am concerned about how I would get billed due to emergencies. More specifically:

What would happen if I got hit by a car, had to go to an out of network ER, and racked up a large medical expense? Would that count towards my PPO out of pocket maximum? What if I was then admitted to the hospital and then subsequently billed for inpatient services? Because they are out of network, would those expenses contribute to my out of pocket max even though the initial reason for going to the hospital was due to an emergency?

If you guys could shed some light on this, that would be much appreciated. I spent the past weekend trying to figure this out and I couldn’t find any answers.

submitted by /u/noodles434
[link] [comments]
So, I’m currently shopping for a Blue Cross Blue Shield Insurance Plan for Illinois during open enrollment for 2021 on their website. I’m deciding between the Silver 303 and Gold PPO 204 plans (leaning towards the silver) and one of the things that seemed concerning was the individual out of pocket maximums (they are identical for both plans). PPO Silver 303: https://www.bcbsil.com/ooc/ind/ooc-spsh41bceiilo-il-2021.pdf PPO Gold 204: https://www.bcbsil.com/ooc/ind/ooc-gpsh30bceiilo-il-2021.pdf Individual Out of Pocket Expense Limit for Participating Provider: 8,550 Individual Out of Pocket Expense Limit for Non-Participating Provider: Unlimited At first glance, it seems like if I go out network, I won’t have an out of pocket maximum since it’s unlimited. So I called customer service and they said the following: I can go out of network and that would count towards my 8,550 out of pocket max if they accept my PPO. This was slightly confusing because doesn’t out of network imply that it is not a participating provider? What’s the difference between a participating provider and non participating provider? In network and out of network? Additionally, because of the unlimited out of pocket expense for non-participating providers, I am concerned about how I would get billed due to emergencies. More specifically: What would happen if I got hit by a car, had to go to an out of network ER, and racked up a large medical expense? Would that count towards my PPO out of pocket maximum? What if I was then admitted to the hospital and then subsequently billed for inpatient services? Because they are out of network, would those expenses contribute to my out of pocket max even though the initial reason for going to the hospital was due to an emergency? If you guys could shed some light on this, that would be much appreciated. I spent the past weekend trying to figure this out and I couldn’t find any answers.
submitted by /u/noodles434 [link] [comments]Read Morer/HealthInsurance

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