What’s the Difference Between In-Network and Out-of-Network?

If you have a health insurance plan, you’ve probably come across the terms “in-network” and “out-of-network.” Simply put, in-network means the doctors or hospitals you visit contract with your insurance, so you typically pay less. With out-of-network care, the providers don’t have an agreement with your insurance company, which likely leaves you with a higher bill.e60dc2a1-f33c-4a05-9b50-8e3e8e59762965731295-38a6-48ff-90f0-41a6850d50c0
What Does In-Network Mean? What Is In-Network? In-network means your insurance company has a contract with certain doctors, health professionals, pharmacies, or medical facilities. When you visit these specific providers or receive these services, you receive a discounted rate. That’s because your insurance company has negotiated a lower rate for these providers or services, and they pass those savings along to you.e60dc2a1-f33c-4a05-9b50-8e3e8e5976290d7139e3-40bf-40b7-bf2f-557dadcc8dc0 In-network doesn’t necessarily mean “free,” though. Your insurance company will probably share the lower bill with you in some form. Depending on your plan, you may have to pay: A copay: A small fee for the health service Your deductible: A set amount you pay before your insurance kicks in Coinsurance: A percentage of the bill that you share with your insurance after you reach your deductible In most cases, the agreed-upon amounts for a copay, deductible, or coinsurance are only for providers and services that are in-network.e60dc2a1-f33c-4a05-9b50-8e3e8e597629c1727c13-832e-426e-bd7c-7d17dbccebbf
What Does Out-of-Network Mean? What Is Out-of-Network? Out-of-network providers don’t have a contract with your insurer, so your insurance company will be charged the full price for the services you receive. This usually means you’ll pay much more. Sometimes, your costs may not be covered at all, unless it’s an emergency.e60dc2a1-f33c-4a05-9b50-8e3e8e59762996c1001a-99ec-49b0-8928-a3deaa112772 When you go out-of-network, your copays, deductibles, and coinsurance might all be much higher.e60dc2a1-f33c-4a05-9b50-8e3e8e597629b84c9045-b71e-45bb-8d47-eeead7b06653
How Do I Know if a Doctor Is In-Network or Out-of Network? Is My Doctor In-Network? You should always verify that your preferred doctors, pharmacies, and hospitals are in-network. Here’s how. Check your health insurance’s website. Many companies provide a list of in-network providers. Call your insurance company. Ask a representative if your provider is in-network. Contact your provider. Call or check their website. Many hospitals and doctor’s offices will list the insurance plans they accept.e60dc2a1-f33c-4a05-9b50-8e3e8e5976293870dc33-da27-4f76-81bc-570513be21d2
How Much More Will I Pay for Out-of-Network Doctors? Out-of-Network Costs It depends on your provider and your plan. An out-of-network doctor can charge you the full price for a visit because they don’t have any deals with your health insurance company. Some insurers will help you with these extra costs, but others will not contribute at all.e60dc2a1-f33c-4a05-9b50-8e3e8e5976291d38f1f2-4b5c-4065-889c-0f143083fa6b According to one eHealth survey, people who used out-of-network doctors spent nearly $900 more, on average, for their care than those who stayed in-network. But these costs can be even higher.e60dc2a1-f33c-4a05-9b50-8e3e8e59762971669134-39d6-42f9-8ffd-fbfe20f7f28f Though there’s a federal cap on what patients can spend out of pocket, this applies only to in-network care. That means the amount you owe for out-of-network care can be unlimited.e60dc2a1-f33c-4a05-9b50-8e3e8e597629bc5b1e03-87a5-4380-8406-fd5a0edcc7bf If your insurer does cover some out-of-network costs, they will likely provide you with an estimate of the amount you can expect to pay. You may have different out-of-network copays, coinsurance, deductibles, and out-of-pocket maximums. Most of the time, these charges are higher than if you stayed in-network.e60dc2a1-f33c-4a05-9b50-8e3e8e597629e57a5902-6529-4d7a-883d-5e0ad1a84d10
What Happens if I Go Out-of-Network for Emergency Care or While Traveling? Emergencies and Traveling In emergency situations, you may have to go to the nearest medical facility quickly, whether it’s in-network or out-of-network. The No Surprises Act covers you if this happens. The law says that you are protected from surprise bills in emergency situations or if you unintentionally see an out-of-network provider at an in-network facility.e60dc2a1-f33c-4a05-9b50-8e3e8e597629d675a879-3f9a-4713-9bf5-71d77c72c930 If you go out-of-network while traveling, you may still have to pay extra out-of-network costs. Some plans will offer access to in-network providers outside your state for non-emergencies. Emergency care is typically covered if you’re traveling within the United States. But some plans may not offer emergency coverage outside the United States. You will have to check with your insurer.e60dc2a1-f33c-4a05-9b50-8e3e8e597629bd2b5417-54f2-401d-a097-4477cd3c22d4 If you’re concerned about medical costs while you’re away from home, you may want to purchase supplemental travel insurance.
Do HMO and PPO Plans Both Offer Out-of-Network Benefits? HMO vs. PPO Preferred provider organizations (PPOs) are generally more flexible and offer out-of-network benefits. For an additional fee, you can use providers outside of your network without the need for a referral. But you will still pay less if you use in-network providers. On the other hand, health maintenance organizations (HMOs) typically limit you to in-network care, except if it’s an emergency. With HMOs, you usually must use in-network providers. Additionally, you usually need a primary care doctor to give you a referral for specialists.e60dc2a1-f33c-4a05-9b50-8e3e8e5976292b726889-e79c-4cf7-ba84-32e435403fbd
The Takeaway In-network doctors and hospitals work with your insurance company to give you a discounted rate. Out-of-network care can be more expensive since your provider doesn’t have a deal with your insurer. Emergencies in the U.S. are covered whether you use an in-network or out-of-network provider. If you have any questions about what’s covered, you should check with your insurance company.
Resources We Trust HealthCare.gov: What You Should Know About Provider NetworksHealthinsurance.org: Out-of-Network (Out of Plan)CMS.gov: Affordable Care Act Implementation FAQs – Set 1Fair Health: Using Health Insurance While Traveling