Having trouble understanding what it means to receive care in or out of network? There are many differences – most notably, the cost you should expect to pay. Many health plans contract with specific providers so their members can receive health services at a more affordable rate. But what happens when you get care out of network? And how do you know who’s a part of your network? Let’s take a look at some of the most commonly asked questions about in- and out-of-network care.

What is a health plan network?

A health plan network is a group of clinics, hospitals, pharmacies and doctors that a health insurer contracts with so their members can get lower costs – kind of like when you buy something in bulk. Since insurers can represent millions of members, they can negotiate better prices for their members.

Insurers regularly evaluate their network providers to ensure they’re providing high-quality care, patient satisfaction and are charging fair prices for services.

Most insurance companies have many networks. They pair each health plan with a network where members of that plan can get covered care. If members get care from in-network providers, they can take advantage of those pre-negotiated discounts.

Getting care in and out of network

When you get care out of network, you’re receiving services from a health care provider who isn’t in the network that your insurer has paired with your specific insurance plan. If you go to a doctor out of network, you will likely have to pay more than you would if you stayed in your network. In some cases, you can end up paying full price if your insurance plan doesn’t have out-of-network benefits.

How in-network care works

When you get care in network, you can be confident that you’re being charged a fair price for high-quality care and experience. You’ll also get the best coverage from your health plan benefits by going to in-network providers, so you’ll pay the least out of pocket.

How out-of-network care works

Out-of-network care is almost always more expensive than in-network care, although it depends on your specific plan. Some insurance carriers may not cover services provided by out-of-network doctors and specialists at all. Others may only provide partial coverage, so you pay more of the cost. Additionally, if you’re on a Medicare plan, anywhere you get care must accept Medicare for it to be covered.

What to know about out-of-network insurance coverage

Insurance carriers usually set a higher deductible and out-of-pocket limit (or even no maximum limit) when members get out-of-network care. Many health plans, like preferred provider networks (PPOs), have one annual deductible for in-network care and another higher annual deductible for out-of-network care.

An out-of-network benefit is the rate at which your plan is willing to contribute to care out of network. In many cases, your out-of-pocket costs could be twice as much or more for the same care if you go out of network. And if your plan has no out-of-network benefits, it means that you’re responsible for the full cost if you receive care from that provider.

How PPO and HMO networks handle out-of-network coverage

There are a variety of types of health plans, but many are PPO or health maintenance organization (HMO) health plans. They work differently for in-network and out-of-network care.

A PPO is a type of health plan that contracts with medical providers, like doctors, specialists and hospitals, as a network of participating providers. PPO networks usually provide some coverage for out-of-network care, but you will pay more for it.

HMO plans generally limit coverage only to care provided by doctors who are in your network, with out-of-network coverage only available for emergency care. If you get care from an out-of-network provider on an HMO plan, you’ll often pay the full cost yourself.

How and why your network providers are chosen

Many factors determine which providers a health plan will contract with and include in each network. Your insurance company carefully researches providers before allowing them in their networks. Insurance companies generally have minimum standards for quality, billing practices, the credentials of clinicians, and more. They also make sure the prices charged are fair and the provider is located within a reasonable distance of where the plan’s members live.

Insurance companies are also usually required to have enough types of different providers in each network that their members can get any type of care they need without waiting too long. That impacts the number and types of providers they include in each network as well.

What determines which providers are in each network?

Most insurance companies have many networks. And not every provider that they contract with is in every network. The network you have depends on the specific plan you have.

Typically, insurance providers pair different networks with different plans to give their members more choices. For example, a plan with a smaller network might have a lower monthly premium or cost-sharing. That’s because the insurance carrier may have negotiated lower rates with those specific providers and can pass the savings onto members of that plan. A different plan may have slightly higher costs but a larger network where you can go almost anywhere. With more providers, the insurance company can’t control the cost of your care quite as well. By offering a variety of plans and networks, insurance plans allow their members to balance what is most important to them: lower monthly costs or more choice of doctors.

Large employers who offer self-insured plans to their employees may also get a say in the providers available in their network, and the types of plan and network combinations offered.

To ensure the provider or clinic you want is included in your plan’s network, it’s best not to assume. Make sure to check your network by signing in to your account.

How to know if your doctor is in network

Knowing if your doctor is covered is important before you begin any course of treatment. Most insurance companies have online search tools to help you find if your provider is in or out of network. HealthPartners members can search online or use the HealthPartners app.

You can also contact your health insurance company’s Member Services at the phone numbers on your insurance card.

It’s important to note that even if a provider is in your network, in some cases, you may need a referral to receive specialized care.

Tiered networks have different levels of coverage

Some plans offer tiered networks. This means you have access to a large network, with all providers confirmed by your insurance company to be high quality, but with some covered at a higher rate than others. Tier 1 offers the highest coverage and lowest cost, while Tier 2 will cover less and cost more and so on. The higher the tier number, the higher the out-of-pocket cost. If you have a tiered network, try to stay in Tier 1 for the most coverage and lowest cost.

Hospitals and doctors: Are they all in network?

It’s common for some types of doctors to see patients at multiple hospitals or clinic locations, such as surgeons or midwives and OB-GYNs.

Just because a doctor practices at a hospital or clinic that participates in your network doesn’t mean that doctor is in your network.

If you’re having a procedure done or delivering a baby at a hospital or surgery center, you should confirm that both the facility and the doctor are in network before you get care. If one of them isn’t, Member Services can help you determine your in-network options.

Is all emergency care in network?

Emergency care within the U.S. must be covered as in-network by your plan even if it’s out-of-network for routine care. This helps ensure you can get care in an emergency from the nearest hospital without worry.

Be sure to check your plan to see what coverage you have for emergency care if you travel outside of the U.S. Many health plans offer services to help members get unexpected care while traveling worldwide.

Coverage for urgent care

For many plans, urgent care is not classified as “emergency care.” And just like doctors and clinics, some urgent care centers are within your network and others aren’t.

It’s important to double check your plan benefits and network information so you know what’s covered before an urgent situation occurs. Make sure you know the nearest in-network urgent care location to your home or work. HealthPartners members can review their benefits and network online or use the HealthPartners app.

When insurance doesn’t cover out-of-network services

In most situations, insurance companies won’t provide extra coverage for out-of-network care. It’s always best to check your network before receiving care to ensure you’re getting the best coverage.