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Visitors Insurance and Out of Pocket Expenses for In-Network Providers

Visitors Insurance and Out of Pocket Expenses for In-Network Providers

Visitors insurance is short-term travel medical insurance that is designed to generally cover any new medical conditions, injuries or accidents that may occur after the effective date of the policy.

Unlike long-term major health insurance plans in the U.S., in most cases, there is no concept of copay for physician visits. However, some visitors insurance plans waive the deductible and you only have to pay the copay for urgent care and/or walk-in clinics.

The United States has the concept of PPO networks where the contracted providers (such as doctors, hospitals, labs, etc.) can bill the insurance company directly and charge you the network-negotiated fees, which are typically lower than their regular fees.

Although various visitors insurance plans provide different benefits and have different rules regarding the deductible, coinsurance and out-of-pocket maximum, it is important to understand how they generally work.

Some of the popular comprehensive visitors insurance plans have coverage as follows:

  1. Deductible waived within PPO network, pays 100% to policy maximum.
    Outside PPO network: After deductible, pays 80% to $5,000, then 100% to policy maximum.
  2. Within PPO network: After deductible, pays 100% to policy maximum.
    Outside PPO network: After deductible, pays 80% to $5,000, then 100% to policy maximum.

After reading the above description, some people mistakenly think that in Plan A, they don’t have to pay anything if they visit an in-network hospital. And in Plan B, they have to pay only the deductible when they visit an in-network hospital. Even though what is written above is not inaccurate, it is very important to understand how the U.S. healthcare system works.

Hospital

When you visit a hospital that is within the PPO network, in-network charges and coinsurance (such as 100% within network etc.) rules would apply.

However, it is important to understand that everyone that could end up treating you in the hospital may not be in the network. There may be workers in the hospital such as the treating physician, anesthesiologist, surgeon, assistant surgeon, imaging technicians, etc. that are independent contractors who may not be in the network.

Therefore, when you get treatment at an in-network hospital, you will not get only one bill. You will get various bills from the different people who treated you. The insurance company will process each bill accordingly whether the provider is in network or out of network.

When you urgently need treatment, the most you can control is whether the hospital is in the network or not. Sometimes, this may not even be a choice for you. But when you visit an in-network hospital, you may not be able to control if everyone that treats you is in network as well. Even if you are in a physical condition to ask each of those providers whether they are in network or not, they may give answers like, “I am not involved in billing as that is handled from Colorado (and you are in Dallas),” or, “I am not in network but I am the only one available to treat you.” At that point, there is really nothing you can do but get the treatment and hope that they are in network.

You might think that it is really unfair. However, at this point, we are not describing any specific health insurance (or visitors insurance), but rather how U.S. healthcare works in general.

Many providers in the emergency room purposefully don’t join any network because they know that you don’t have any choice. Unfortunately, there are currently no rules or regulations that prevent such predatory practices. Some states may have surprise billing laws. Please make sure to check the details of the specific state where treatment may be received.

In any case, the insurance company (whether domestic health insurance or visitors insurance), will process each bill according to whether the provider is in network or out of network.

Hospital Emergency Room

People should visit a hospital emergency room when it is a true emergency. Otherwise, they should consider visiting an urgent care facility. Read about choosing the right provider.

To discourage patients from visiting the emergency room for non-emergency situations, each health insurance (domestic or visitors) has penalties in some circumstances.

For example, in some of the popular comprehensive visitors insurance plans, the following rules apply:

  1. Extra $200 copay for illness visit that does not result in hospital admission.
  2. Extra $250 deductible for illness visit that does not result in hospital admission.

All visitors insurance plans have similar clauses. Most domestic health insurance plans (such as the ones you get from your employer) have a $500 or $600 copay for each ER visit, no matter what.

Therefore, you may end up paying this additional copay under such circumstances, even if you have otherwise chosen a $0 deductible. No matter what deductible you have chosen, this payment is additional and applies to each ER visit.

Pharmacy

None of the visitors insurance plans participate in any PPO network for pharmacies. Therefore, you must pay out of your pocket and file for reimbursement of eligible expenses.

Therefore, if you have any pharmacy claims, out-of-network rules will always apply.

If any of the visitors insurance plans come with a prescription drugs discount card, you can use that at the pharmacy which will help reduce the overall cost and therefore, will also help reduce the out-of-pocket cost.

FAQ

Q: If I have chosen a $0 deductible. I don’t have to pay anything. Is that correct?

A: No. Please read the various descriptions above. You are still responsible for the applicable copay and coinsurance.

Q: If the plan waives the deductible within the PPO network, I don’t have to pay anything in network. Is that correct?

A: No. Please read the various descriptions above. You are still responsible for the applicable out-of-network deductible as well as the copay and coinsurance.

Therefore, without understanding it fully, you should not automatically choose a $5,000 deductible thinking that you will always go in network and save some on your premium. Of course, it is possible for some customers, but it may not be possible for everyone.

Conclusion

The U.S. healthcare system is complex and difficult to understand even for those who have lived in the U.S. for a long time, even for the professionals. While we try our best to explain as much as we possibly can for various scenarios, there is always more to learn.

Please review the certificate wording carefully to understand the plan benefits before making a decision to purchase any visitors insurance.

If you have any questions, please feel free to contact us at any time and we would be glad to help you answer your questions.


Did you know?

Prices are regulated by law.

You cannot find a lower price anywhere for the same product.

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Why purchase insurance from Insubuy®?

Same Price. Better Service.®

There are many advantages in purchasing from Insubuy® and no disadvantages.

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Visiting USA?

Healthcare costs are very high in the U.S.

Buy U.S. based visitors insurance and enjoy your trip.

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Traveling abroad?

Did you know that your insurance may not cover you abroad or that it may only provide limited coverage?

Purchase travel medical insurance that includes emergency medical evacuation.

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New immigrant to USA?

You are not eligible to enroll in Medicare for the first 5 years.

Purchase new immigrant medical insurance to bridge the gap.

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Going on a vacation?

You could lose your non-refundable trip costs if you had to cancel your trip.

Buy a trip cancellation insurance package plan and be worry-free.

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Are you an exchange visitor to USA?

The U.S. Department of State requires all J visa holders to purchase compliant insurance.

Buy J visa medical insurance to meet your requirements.

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Traveling to Europe?

Schengen countries require most non-US citizens to purchase Schengen visa insurance.

Make an instant purchase online and get instant visa letter.

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Traveling frequently throughout the year?

You don't need to purchase travel insurance for every trip.

Purchase annual multi trip travel insurance for your travels.

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International student in the U.S.?

Most schools require international students to purchase health insurance.

Purchase international student health insurance that meets most school requirements.

Learn More