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.

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Topic Area: Provider networks and referrals

What are provider networks?

Provider networks are made up of doctors, other healthcare providers, pharmacies, and facilities who contract with insurance companies to become an "in-network” provider. If you go to a provider who is in your insurance company's network, you will typically pay less than if you go to an “out-of-network” provider who doesn't have a contract with your insurance company.

Insurance companies have different networks of healthcare providers for different health plans, so it’s important to check if a provider is in or out of your plan’s network before you receive services.

Know your plan coverage for out-of-network services

  • Some insurance plans will not cover out-of-network services. 
  • Other plans may provide coverage for a percentage of the charges, but you are responsible for the remainder of the costs including possible balance billing charges.
  • Your insurance plan will provide out-of-network coverage for an emergency.
  • Your insurance company may approve out-of-network care for specialized services not available in your plan network. You’ll want to get this approved in writing in advance of receiving services to avoid unexpected costs.
  • Don't expect your healthcare provider to know what other providers are in your network.  Check with your insurance plan if you are referred to another provider for services to verify they are in-network providers.

Remember, your costs will generally be higher for out-of-network providers than if you see an in-network provider. Check with your health insurance plan to see if a provider is in-network before you receive care.   

Helpful Tips

  • Make sure you know the provider network included in your insurance plan.
  • Don't assume a healthcare provider is in-network for your health plan.
  • Call your insurance plan for the most current information to avoid unexpected costs.

Know in-network resources before you have an urgent need!

In-network - The facilities, healthcare providers, pharmacies, and suppliers that your health insurance plan has contracted with to provide services. Their contract sets the payment for the services they provide. You will pay less for healthcare services received in-network than services received out-of-network.

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

6/10/2024

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