Will My Tennessee Marketplace Health Plan Pay Anything If I See an Out-of-Network Doctor?

Quick answers

Will my Marketplace plan pay for an out-of-network doctor in Tennessee?

It depends on your plan type. HMO and EPO plans usually cover only in-network care, except emergencies. PPO and POS plans pay part of out-of-network care, but you pay more than you would in-network. Check your plan type before you book.

What is the difference between an HMO, EPO, PPO and POS plan?

HMO and EPO plans generally require using doctors and hospitals in the plan's network. PPO plans let you go out of network for a higher share of the cost. POS plans do too, and usually require a referral to see a specialist.

Does my Marketplace plan cover emergencies out of network?

Yes. HMO, EPO, PPO and POS Marketplace plans all cover emergency care even when the doctor or hospital is out of network. Emergencies are the main exception to network rules. Regular visits out of network can cost more or not be covered at all.

How do I find out what type of Marketplace plan I have?

Check your plan documents or the information you received when you enrolled. They show whether you have an HMO, EPO, PPO or POS. Then confirm your doctor is in the plan's network before you schedule an appointment. A licensed agent at The Jordan Insurance Agency can review this with you by phone or video.

In this episode

Learn how Tennessee Marketplace health plans handle out-of-network doctors. Billy Jordan of The Jordan Insurance Agency explains which plan types pay for out-of-network care and what to check before your next appointment.

• How HMO, EPO, PPO, and POS plans in Tennessee handle out-of-network care
• When emergencies are covered by Marketplace health plans in Tennessee
• Tips to avoid surprise bills by checking your plan and doctor’s network status

Source: How to pick a health insurance plan (healthcare.gov)

Billy Jordan is a licensed insurance agent (NPN 8699876) with The Jordan Insurance Agency, with an office in Nashville, Tennessee. Voices in this episode are AI-generated, including Billy's, from a script reviewed and approved by Billy Jordan, a licensed insurance agent. General education only, not advice for your specific situation.

Tanya (AI host): If I have a Marketplace health plan here in Tennessee, will it pay anything if I see a doctor who’s not in the network? The answer depends a lot on your plan, so stick around.

Tanya (AI host): Welcome to Smart Coverage. Real Advice., the insurance podcast from The Jordan Insurance Agency. I'm Tanya, your host, and I'm here with Billy Jordan, a licensed insurance agent and the president of The Jordan Insurance Agency.

Billy Jordan: Glad to be here, Tanya. This is a question I hear a lot, and it’s important for folks in Tennessee who want to make sure they’re not caught off guard by a surprise bill.

Tanya (AI host): So let’s get right to it. According to healthcare.gov, what happens if I see a doctor outside my Marketplace plan’s network—will my plan pay anything?

Billy Jordan: That really depends on the type of plan you have. Some Marketplace plans, like HMOs and EPOs, usually only cover care if you see doctors in their network, except in emergencies. On the other hand, PPOs and POS plans are more flexible—they’ll pay something for out-of-network care, but you’ll pay more out of your own pocket. So, the short answer is: your plan might pay, but it’s not guaranteed, and it’s usually more expensive.

Tanya (AI host): That’s a big difference. Can you break down those plan types a little more? What do all those letters mean in plain English?

Billy Jordan: Sure! HMO stands for Health Maintenance Organization. If you have an HMO, you’re generally required to use doctors and hospitals in the plan’s network. Out-of-network visits usually aren’t covered at all unless it’s an emergency. EPO is Exclusive Provider Organization, and it’s similar—you have to stay in-network for coverage, again with exceptions for emergencies.

Tanya (AI host): So, if I have an HMO or EPO, and I just decide to go see a doctor who isn’t in the network, I’m probably paying the whole bill myself?

Billy Jordan: Exactly. Unless it’s an emergency, you’re on the hook for the full cost. That’s a common surprise for people.

Tanya (AI host): What about PPOs and POS plans—how are those different when it comes to out-of-network doctors?

Billy Jordan: PPO stands for Preferred Provider Organization. With a PPO, you can see doctors outside your network, and your plan will pay part of the bill, but you’ll still pay more than if you stayed in-network. POS means Point of Service. It’s similar: you pay less if you use network providers, but you can go out-of-network if you’re willing to pay more, and you usually need a referral to see a specialist.

Tanya (AI host): That sounds a little more flexible. Can you give a general example of how that might play out for someone in Tennessee?

Billy Jordan: Sure. With a PPO or POS plan, if you see a doctor outside your network, your plan may pay a portion of the cost, but your share will be higher than if you use a network doctor. With an HMO or EPO, out-of-network visits are generally not covered unless it’s an emergency, so you would pay the full amount.

Tanya (AI host): So the big thing is to check your plan type before you go out-of-network. What’s a common mistake people make with this?

Billy Jordan: One mistake I see a lot is folks assuming all plans work the same and that they can just go to any doctor they want. But if you don’t know your plan type, you could get a big bill you weren’t expecting. Another mistake is forgetting to check if a provider is actually in your network before making an appointment.

Tanya (AI host): That could be an expensive surprise. According to healthcare.gov, do any of these plans ever cover out-of-network care for emergencies?

Billy Jordan: Yes, they do. All of the plan types mentioned—HMO, EPO, PPO, and POS—will cover emergency care even if the provider is out-of-network. Emergencies are the main exception to those network rules.

Tanya (AI host): So if it’s a true emergency, you’re covered, but for anything else, it really depends on your plan type.

Billy Jordan: Exactly. For regular checkups or planned visits, you want to stay in-network unless you have a plan that helps with out-of-network costs, like a PPO or POS. And even then, expect to pay more.

Tanya (AI host): How can someone in Tennessee find out what type of plan they have?

Billy Jordan: You can check your plan documents or information you received when you enrolled to see what type of plan you have. It’s a good habit to double-check before you schedule any appointments.

Tanya (AI host): That’s an easy step, but one a lot of people skip. Can you sum up what someone in Tennessee needs to remember about out-of-network coverage on Marketplace plans?

Billy Jordan: Sure thing. First, know your plan type. If it’s an HMO or EPO, you’re usually limited to in-network providers unless it’s an emergency. With a PPO or POS, you have some out-of-network coverage, but it’ll cost you more. And always confirm your doctor’s network status before you go.

Tanya (AI host): Three things to remember. One, your Marketplace plan type—HMO, EPO, PPO, or POS—makes all the difference for out-of-network coverage. Two, emergencies are always covered, but regular visits out-of-network can be costly or not covered at all. Three, always double-check your plan details and your provider’s network status before seeing a new doctor.

Tanya (AI host): For a personalized look at your situation, book a free thirty-minute chat with Billy and his team at thejordaninsuranceagency.com/podcast.

Billy Jordan: I'm Billy Jordan with The Jordan Insurance Agency. Until next time, take care.

Tanya (AI host): Thanks for listening to Smart Coverage. Real Advice. from The Jordan Insurance Agency.