Many individuals are working remotely these days. Unfortunately, many remote employees may not realize that their health insurance network of providers may not extend to their county of residence.
It is important to understand separate out-of-network deductibles, co-insurance, and excess charges related to out-of-network care. More importantly, remote workers need to understand that out-of-network providers can charge whatever they like! Out-of-network providers have no contract with the Arizona health insurance company and do not have to abide by reasonable and customary rates. The insurer may pay a portion of the out-of-network charges if the employee is enrolled in a PPO as an example, but the gap between what the insurer pays, and the provider charges can be substantial, and the employee must pay this excess charge. Adding insult to injury, the insurance company will not apply the excess charges to the employee’s annual out-of-pocket maximum.
Remote workers covered through an HMO most likely have no coverage outside the service area of the HMO except in emergencies. The employees broken leg would be covered, as this requires emergency care, but any therapy required afterward would not be covered out-of-network. This means a trip into town (or another state possibly) every time a follow-up doctor visit is scheduled.
If the employer is self-insured many times the employer has more flexibility when it comes to what is and is not covered, who may be covered, where coverage may be provided, and who may provide coverage. This is not the case with fully insured group health insurance plans. The self-insured employer need not follow an insurance company’s rules or provider network guidelines as they are technically the insurance company. Most large employers are self-insured, using a health insurance company to process claims and issue member ID cards, etc.