You’ve probably heard the terms “in-network” and “out-of-network” when it comes to health insurance. But what do they actually mean—and why should you care?
Let’s say you just started a new job and now have different health insurance. After visiting your regular doctor, you find out they’re no longer in your plan’s network. That means they’re considered “out-of-network,” and you’ll likely have to pay more to keep seeing them. Or, you might need to switch to a doctor who is “in-network” to save money.
That’s why understanding provider networks is important. When picking a health plan, make sure it includes your preferred doctors and hospitals. It can save you both money and stress.
So, what’s a provider network?
A provider network is simply a group of doctors, hospitals, clinics, and other healthcare providers that have partnered with your insurance company. They’ve agreed to offer services at lower, negotiated rates.
These in-network providers can include:
- Primary care doctors
- Specialists
- Hospitals
- Urgent care centers
- Pharmacies
- Labs
- Medical equipment suppliers
When you see someone in-network, your insurance covers more of the cost. Seeing someone out-of-network usually means paying more—or sometimes everything—out of your own pocket.
In-Network vs. Out-of-Network: What’s the Difference?
Here’s a quick breakdown:
- In-network: These doctors and providers have a deal with your insurance to offer discounted care. You pay less out of pocket.
- Out-of-network: These providers don’t have that deal. You’ll likely pay much more—and your insurance might not cover anything unless it’s an emergency.
That’s why it’s smart to check which doctors and hospitals are included in your plan before signing up—especially if you regularly see a certain provider or need ongoing care.
Also Read: How do Insurance Premiums Work?
How Does Using In-Network Providers Save You Money?
Using in-network care saves you in a few ways:
- Lower prices: Your insurer negotiates discounts with in-network providers, so costs are lower.
- Lower out-of-pocket costs: Things like copays, deductibles, and co-insurance are typically cheaper.
- Billing is simpler: In-network providers bill your insurance directly. You’ll only get a bill after your insurance processes the claim, so you’re not stuck paying the full amount upfront.
Pro tip: Even if your provider is in-network, not all services may be covered. Always double-check if a specific procedure requires prior approval or is part of your plan. It can save you from surprise bills later.
Do Different Insurance Plans Have Different Network Rules?
Yes, absolutely. Some plans only pay for in-network care, while others give you more flexibility (but may cost more).
Here’s a quick guide:
- HMO (Health Maintenance Organization): Covers only in-network providers. Out-of-network care isn’t covered unless it’s an emergency or pre-approved.
- PPO (Preferred Provider Organization): Offers both in-network and out-of-network coverage. You pay less with in-network providers but still have the freedom to go out-of-network.
- POS (Point of Service): A mix of HMO and PPO. You need a primary doctor and referrals (like an HMO), but you can see out-of-network providers (like a PPO).
- HMO-POS: Similar to an HMO but lets you see Medicare-approved providers outside the network—though you may pay more.
Bottom line: Know your plan type. HMOs are stricter, PPOs and POS plans give you more options—but at a cost.
Also Read: What’s the Difference Between Medicare and Medicaid?
How Can I Find In-Network Providers?
There are a few easy ways:
- Check your insurer’s website: They usually have a directory where you can search for doctors, hospitals, and more.
- Call your insurance company: They can confirm which providers are in your plan’s network.
- Ask your provider’s office: Many doctors list the plans they accept on their websites—but it’s always smart to call and double-check.
Should I Look at Provider Networks When Choosing a Plan?
Absolutely. Besides just looking at premiums or deductibles, check which doctors and hospitals are in the plan’s network. Here’s how to do it:
- Make a list of your current doctors and facilities.
- Compare plans to see if they’re in-network.
- Think ahead: Are you planning to have a baby? Do you have a condition like diabetes? Make sure the specialists you may need are included in the plan—and nearby.
A strong provider network helps ensure you get the care you need—both now and down the road.
