In Network vs Out of Network Health Insurance Coverage and Open Enrollment

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Summary

In this video, we clarify the distinction between in-network and out-of-network healthcare coverage and explain the concept of open enrollment. In-network providers have agreements with insurance companies, resulting in lower costs for policyholders. Out-of-network providers operate independently and can charge higher rates. Dental plans similarly have set coverage limits. We stress the importance of confirming a provider's network status before treatment. Open enrollment, which occurs annually, is the designated time for modifying coverage. Changes outside this period require qualifying life events, such as job changes or marriage, with a 30-day window for adjustments. Necessary documentation for life events is highlighted, and viewers are encouraged to contact their benefits department for further information.

Transcript

Welcome back. In this video, we will be discussing the difference between in network coverage and out of network, as well as open enrollment.

Let's get started. Okay. So now you have health insurance, but now it's time to decide what doctor to choose.

First, let's talk about in network coverage.

For in network coverage, certain practices and doctor's offices have contracts with the insurance companies to accept discounted rates.

This means you pay less for services.

Now, out of network providers work entirely different. They offer no contracts with insurance companies. They can charge any rate they want.

Medical plans typically have a separate higher deductible and out of pocket maximum for out of network providers.

Dental plans will usually only pay up the reasonable and customary charge that would be found for an in network provider.

So any amount over that would be owed by the patient.

It's very important that before you seek treatment from a provider, you need to find out if they are in fact in network or if they are out of network so that you're prepared for any potential charges.

So when can you make changes to your coverage?

Let's talk open enrollment.

The government puts strict rules around when you're allowed to enroll, make changes, and unenroll from your insurance coverages.

Otherwise, people would only purchase insurance when they need it, making it incredibly expensive.

So when exactly can you make changes?

Open enrollment occurs once a year, which gives everyone an opportunity to make any changes to their elections.

Outside of open enrollment, you would need a qualifying life event to make any changes.

Now, a qualifying life event includes but not limited to starting a new job or leaving your current job, having a baby, getting married, or simply losing coverage due to no longer being a qualified dependent.

There's only a thirty day window to make your changes from the date of your qualifying life event.

Because there are so many different qualifying life events, there can be unusual circumstances surrounding them. Always reach out to your benefits department to see if you have a qualifying life event.

All of these require submitting documentation to support the event. For a list of documentation, you'll want to reach out to your benefits department.

And that wraps up today's video. Thanks for watching.