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- Out-of-Network Benefits: Many insurance plans have provider panels, which are the professionals whose services the plan will pay the maximum benefit for. Some plans allow members to “swing out” of the panel and see any provider they choose. The main disadvantage of going outside your network is that you may have to pay a deductible, or a higher deductible, and your co-payment is often higher than if you use a provider who is in the network (i.e., on your plan's panel).
Pre-authorization of services: Some plans require you, the member, to call in advance of your appointment to receive authorization (e.g., payment) for a covered service. Failure to obtain pre-authorization can result in the member being responsible for the entire fee for the appointment.
Deductible: A deductible is the amount a member must pay out-of-pocket before insurance benefits kick in. Deductibles are often listed dually, by individual and family. In other words, if you have a $300/$900 deductible it means that $300 must be met for one family member OR $900 by the family before insurance will begin paying for services. Deductibles correspond to your plan’s policy year (e.g., calendar or fiscal).
Co-payment: A co-payment is the portion of the charge for the appointment that the member is responsible for. This amount may be a specific dollar amount, a percentage of the total charge, or a combination of the two.