What is in-network vs. out-of-network benefits?

The amount of benefits paid to a covered person is based on whether a provider of services participates in a network or not. Health care providers in a carrier’s network have agreed with the carrier to a negotiated rate of payment. Any charges in excess of the negotiated rate of payment cannot be billed to the insured person. When a covered person chooses to receive covered services out-of-network, the person is responsible for any charges that the health care provider may bill that exceed what the carrier considers to be reasonable and customary. This is known as “balance billing”. These excess charges do not count toward satisfying any deductible or MOOP requirements in the standard health benefits plan.

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