Your plan may contract with doctors, dentists and other healthcare practitioners; hospitals; labs; radiology facilities; pharmacies and other types of providers. These are the providers in your “network.” Each provider has agreed to take your plan’s rate as payment in full for medical services. You can usually find a directory of your network on your plan’s website.
If you visit providers outside your plan’s network, you will likely have higher costs, for two reasons. First, these providers have not contracted with your insurer, and may charge more than what your insurer pays. Second, your plan may require higher copays, deductibles and coinsurance for out-of-network care. Often, you’ll have to pay those higher costs. You also will have to pay any difference between what your insurer pays and what the provider charges. Certain types of health plans with “closed networks”, such as an EPO, will not cover any care outside the provider network at all. This means you will have to pay the full cost yourself.
Some people may choose to see doctors outside their plans. But much more often, patients get surprised by an out-of-network bill when they thought they had only used in-network providers. This happens most often with complex services, like surgeries. In those cases, many providers are involved in your care. They may include out-of-network docs at in-network facilities.
If your insurer offers a choice of different plans, look up the network in each. Make sure you are able to get the care you need. Find out:
- Are all of your current doctors in the network?
- Does the network include the hospitals with which your doctors are affiliated?
- How many network providers are close to where you live and work?
- How much would the plan pay for out-of-network care?
Before scheduling a visit with a new provider, ask if he or she takes part in your plan. Also, ask if he or she takes part in the specific network you belong to in that plan (PPO, POS, EPO or HMO). If you choose to go out of network, ask the provider’s staff how much he or she will charge. You can see if it’s in line with other providers’ fees in your area. To do that, use the medical and dental cost lookup tools on this website.
You probably see a lot of references to in-network and out-of-network care on your insurer’s website or in your plan materials. But you may be wondering, how do plans choose their networks? And, how are they making sure you get the care you need?