What are provider networks?

Answer: 

Visual diagram of provider networks, depicting

Doctors and other health providers and facilities often contract with insurance companies to become part of their "network." The contract spells out what they will be paid for the care they provide you. If you go to a provider in your insurance company's network, you will most likely pay less out of pocket than if you go to a provider who doesn't have a contract with your insurance company. Insurance companies have different networks of health care providers for different health plans.

  • In Network - The facilities, health care providers, and suppliers that your health insurance plan has contracted with to provide services. You will pay less for health care services received in network than services received out of network.
  • Out of Network - The facilities, health care providers and suppliers that do not have a contract with your health insurance plan to provide care to you. You will pay more for health care services received out of network than services received in network.

Make sure you know the correct health care provider network associated with your insurance plan. Don't assume that a specific health care provider is in network for your health plan, even if the provider is in network in other plans offered by the health insurance company.

With most Health Maintenance Organization (HMO) plans, you will not receive any coverage if you visit a provider who is out of network, except in an emergency or if your insurance company approves out-of-network care for specialized services not available in network. If you have a health plan that isn't an HMO and provides some coverage for out-of-network providers, your liability will still be a lot higher than if you visited an in-network provider because cost-sharing and provider billing rates for out-of-network providers are usually much higher.

It's really important to know which providers are covered by your health insurance plan, so contact your insurance company if you have any questions about specific providers that are in network and out of network. Don't rely on your health care provider to know what network you are covered by, especially if you are referred to a specialist.