Navigating the System / Provider networks and referrals
No, you are responsible to check if a provider is in your network. Every insurance company has different benefit plans and network requirements. It is also common for healthcare providers to move in and out of different health plan networks, making it hard for your doctor to know what providers are included your network. However, your provider’s office will often help you by contacting the insurance company to make sure the referral is in your network. Ask your provider for assistance if you…
Navigating the System / Provider networks and referrals
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-…
Navigating the System / Provider networks and referrals
When your doctor needs to refer you to a specialist for care, first talk with the doctor’s office staff to see if there is an in-network specialist contracted with your insurance plan. Remember that the doctor’s office may not know what providers are included in your insurance plan network. If in doubt, call your plan customer service directly.
If you find that your insurance network does not include the needed specialty provider, coverage for services depends on your insurance plan benefits…
Navigating the System / Provider networks and referrals
A referral is like getting a prescription from your regular doctor to go see a specialist. Referrals have expiration dates. Some have a limit on the number of visits. So, if you need to see the specialist after the end date on the referral or for more visits, you will need to get another referral.
You could pay a lot more
If your plan requires a referral but you don’t get one, you could pay a lot more. For example, your plan may charge you a penalty, cover the visit at a lower level, or not…
Navigating the System / Provider networks and referrals
Often, when doctors are out sick, their office staff calls to notify patients and reschedule appointments. Sometimes, instead of rescheduling appointments, a doctor may refer patients to another doctor.
If you plan to see a doctor that is covering for your primary care provider, it is your responsibility to confirm that the covering doctor is in-network before you receive care. Learn more about provider networks.
Failure to confirm that you are seeing an in-network doctor can result in…
Navigating the System / Provider networks and referrals
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…
Navigating the System / Provider networks and referrals
What are narrow network plans?
A narrow network plan refers to a health insurance plan with a smaller than usual, or “narrow,” provider network. In a narrow network plan, health insurance companies try to lower costs by working with a smaller number of providers and fewer in-network facilities. Narrow network plans are offered by employers, through the Health Insurance Marketplace (www.HealthCare.gov), and in Medicare and Medicaid plans.
Why might you choose a narrow network?
The main…