Navigating the System

Empower yourself as a patient, and learn how to get the most out of your benefits. Each plan is different, so this section of our guide will help you understand what it is that you should look for when you receive your insurance information.  This section will help you navigate the health care system when you need care.

Topic Area: Provider networks and referrals

How does insurance coverage differ between in-network and out-of-network providers?

Out-of-network services typically cost you more

Your insurance plan has contracts with doctors, other health professionals, pharmacies, and facilities to provide needed care and services, known as benefits, for plan members.  “In-network” is the term used to describe these contracted providers. The plan pays the in-network providers an agreed rate for care and services, usually at a discount. This reduced rate means that services typically are provided at a lower cost to you.  

Out-of-network” providers are those healthcare facilities, pharmacies, and professionals who do not have a contract agreement with your insurance plan.  Because there is no previously agreed charge for services, the service provider bills their full charges, which means higher costs for you, including balance billing. Payments you make to these providers may not apply toward your out-of-pocket maximums or your deductible.


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