What’s the Difference Between In-Network and Out-of-Network?
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When your health insurance plan has a contract with a doctor or hospital, that provider is “in network.” When there is no contract, the provider is “out of network.” This single distinction can change your bill by hundreds or even thousands of dollars for the exact same service.
Key Takeaways
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In-network providers agree to negotiated rates with your health plan. Your plan’s in-network cost-sharing rules apply, and providers generally can’t balance bill you for covered in-network services.
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Out-of-network care can come with higher deductibles and coinsurance. In situations where balance billing is permitted, a provider may also bill you for the difference between its charge and your plan’s allowed amount.
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Emergency services at an emergency room are generally covered at in-network cost-sharing levels under federal law, even if the hospital or doctor is out of network.
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Plans that cover out-of-network care may apply separate deductibles or other cost-sharing rules. Out-of-network costs and amounts charged above a plan’s allowed amount generally don’t count toward a Marketplace plan’s in-network out-of-pocket maximum.
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Coverage Fox can help you compare marketplace plans, check which healthcare providers they include, and choose coverage that fits your budget and preferred doctors.
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Use your insurer’s provider directory or app. Search by exact plan name, not just the insurance company name. Enter your doctor’s name and facility to confirm participation.
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Call the provider’s office. Ask specifically: “Are you in network with my plan?” Use the full plan name from your insurance card or ID card, such as “Blue Cross Silver HMO” or “Ambetter Balanced Care 20 PPO.”
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Check the network status for planned care. The facility and individual providers involved in your care can have different network status. Federal law protects patients from many surprise out-of-network bills for ancillary services, such as anesthesiology or radiology, received at an in-network facility. It’s still helpful to verify network status before planned care when possible.
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Call your insurer’s customer service number for confirmation, especially before high-cost services.
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A rare condition requires a specialist only available outside your plan’s network.
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The only nearby facility is out-of-network.
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You have an established relationship with a specific care provider.
Understanding Provider Networks in Health Insurance
A provider network is the group of doctors, hospitals, labs, urgent care centers, pharmacies, and other health care providers that contract with a health insurance company to deliver services at agreed-upon prices.
Your insurance plan establishes an allowed amount for covered services. For an in-network provider, that contracted amount helps determine what the plan and member pay for covered care.
Your copay, coinsurance, or deductible is based on your plan’s terms and the applicable negotiated rate rather than simply the provider’s billed charge.
Each health insurance plan, even from the same insurer, can have a different network. A doctor who is in network for one plan may be out of network for another plan from the same insurer. Coverage Fox helps people compare marketplace plans side-by-side by network size, key hospitals, and top specialists so they understand network vs cost trade-offs before enrolling.
What Does “In Network” Mean?
An in-network provider is a doctor, hospital, pharmacy, lab, or other care provider that has a signed contract with your health insurance plan to provide services at agreed-upon prices. For covered in-network services, the negotiated rate generally sets the allowed amount. You pay any applicable deductible, copay, or coinsurance, and the plan pays its share. The provider generally can’t charge you above the allowed amount for the covered service.
Your cost sharing for covered in-network services counts toward your plan’s in-network out-of-pocket maximum. Whether a particular service or payment also applies to your deductible depends on the plan. Once you reach the out-of-pocket maximum, the plan pays 100% of covered in-network benefits for the rest of the plan year.
Some plan types, like HMOs and many EPOs sold on ACA marketplaces, only cover non-emergency medical care when you stay in network.
What Does “Out of Network” Mean?
An out-of-network provider has no contract with your insurance plan, so there is no agreed-upon price for services. The provider can charge their full retail rate, and your plan, if it covers out-of-network care at all, may only reimburse based on its own allowed amount.
In situations where balance billing is allowed, an out-of-network provider may bill you for the difference between its charge and your plan’s allowed amount. That amount can be in addition to any applicable deductible, copay, or coinsurance.
Preferred provider organization (PPO) plans may cover out-of-network care at a higher cost to the member. Health maintenance organization (HMO) and exclusive provider organization (EPO) plans generally limit coverage to in-network care except in emergencies. Point of service (POS) plans can also apply different network and referral rules.
In-Network vs. Out-of-Network Costs: How Big Is the Difference?
The difference between in-network and out-of-network care can show up in your deductible, copays, coinsurance, out-of-pocket limits, and exposure to balance billing.
| Cost Element | In-Network | Out-of-Network |
|---|---|---|
| Deductible | Your plan’s in-network deductible may apply | A separate or higher deductible may apply if the plan includes out-of-network benefits |
| Coinsurance | Generally based on the plan’s negotiated rate and in-network benefits | May be higher when out-of-network care is covered |
| Out-of-Pocket Max | Covered in-network cost sharing counts toward the plan’s applicable maximum | Out-of-network costs generally don’t count toward the Marketplace plan’s in-network maximum |
| Balance Billing | In-network providers generally can’t balance bill for covered services | May occur when permitted, subject to federal and state protections |
Choosing in-network care providers is one of the most effective ways to avoid unexpected costs for individuals and families buying their own health insurance.
How Health Plans Build Provider Networks (And Why It Matters)
A health insurance company builds its provider network by credentialing providers and negotiating contracts that set rates and other participation terms. Marketplace plans use different network designs. HMO and EPO plans generally place tighter restrictions on out-of-network care, while PPO plans generally allow members to use out-of-network providers at an additional cost.
Networks are not static. Contracts expire, and a provider that was in your plan’s network last year may leave this year. Before choosing a plan during Open Enrollment, confirm that your current primary care provider, key specialists, and preferred hospitals participate. HealthCare.gov’s Open Enrollment period runs from November 1 through January 15, while deadlines can differ on state-based Marketplaces.
Coverage Fox’s licensed agents can help you weigh network size against monthly premiums and expected out of network costs.
How to Check Whether a doctor or Hospital Is in-Network
Verifying network status before planned care can help you avoid unexpected medical bills. Never rely solely on a verbal assurance from a doctor’s office.
Emergency Care, Urgent Care, and Out-of-Network Rules
Emergency services follow different network and billing rules than non-emergency urgent care. Under the No Surprises Act (effective January 2022), most health plans must cover emergency services at in-network cost-sharing levels, even if the hospital or emergency physicians are out of network. Your plan cannot require prior authorization for emergency care, and those payments must count toward your in-network deductible and out-of-pocket maximum.
Urgent care centers aren’t treated the same way. Many plans apply in-network benefits only at in-network urgent care centers. Using an out-of-network urgent care center may mean higher cost sharing or no out-of-network coverage, depending on the plan. When coverage begins on a new plan, identify nearby in-network hospitals and urgent care centers so you know where to go when you need care.
Choosing Between In-Network and Out-of-Network Care
Using in-network providers often lowers what you pay for covered routine care because your plan’s negotiated rates and in-network cost-sharing rules apply.
Going out of network might be worth considering when:
Before accepting out-of-network services, request a cost estimate in writing, ask whether any in-network alternatives exist, determine whether preauthorization is required, and clarify how much your plan will reimburse. Understanding your out-of-network benefits before scheduling care can help you avoid unexpected costs.
Frequently Asked Questions
Do preventive services cost less if I use an in-network provider?
Under the Affordable Care Act (ACA), Marketplace plans cover specified preventive services, including certain vaccines and screenings. These services are generally available without copays or coinsurance when you use an in-network provider, although coverage can vary by service.
If you see out-of-network providers for preventive care, you may owe cost sharing, and balance billing may be permitted depending on the circumstances. Check your plan’s Summary of Benefits and Coverage for the full list of covered preventive services.
What if my doctor leaves my plan’s network in the middle of the year?
Providers can leave a plan’s network during the year. If you’re considered a continuing care patient, you may qualify to keep receiving care from that provider at in-network rates for up to 90 days. Contact your insurer to ask whether you qualify and what transition options are available. If you separately qualify for a Special Enrollment Period, Coverage Fox can help you review your plan options.
Will telehealth visits follow the same in-network rules as office visits?
Network and cost-sharing rules can apply to telehealth just as they do to in-person care. Before scheduling a visit, check whether the telehealth provider or platform is in your plan’s network and review the applicable cost sharing.
Do out-of-network costs ever count toward my out-of-pocket maximum?
It depends on the plan. Some PPO plans may have a separate out-of-network maximum. Ordinary out-of-network care and charges above the plan’s allowed amount generally don’t count toward a Marketplace plan’s in-network out-of-pocket maximum. Cost sharing for services protected by the No Surprises Act is treated differently and counts toward applicable in-network limits. Review your plan documents or contact your insurer before scheduling planned out-of-network care.
How often should I recheck whether my providers are still in network?
At least once a year during Open Enrollment, and again before any major service like surgery, childbirth, or expensive imaging. Coverage Fox agents can review networks annually with you to help you avoid surprises when providers or hospitals move in or out of network from one plan year to the next.
