*Content in this blog post is provided courtesy of Blue Cross Blue Shield of North Carolina
Whether you’re signing up for a health plan, searching for a doctor or prescription or just checking to see if you owe anything, the terms “in-network” and “out-of-network” are bound to pop up.
Knowing your insurance plan network is important because most of the time, there’s a difference in your costs between in-network and out-of-network. Over time, these costs can add up.
When selecting a plan, network access is one of your most important considerations. If you’re using existing benefits, your choice of a particular doctor, pharmacy or hospital can make a big difference in the cost, and maybe even the quality of services you receive.
What To Look For
Let’s sort it out in a little more detail.
- Doctors don’t generally get the full cost of their services.
- Your insurance negotiates a lower rate for you from your doctor.
- The doctor joins your insurance company’s network of health care providers and agrees to charge less so you pay less. This is called being in network.
- If you choose a doctor who is out-of-network, and not a partner with your insurer, you may have to pay part or all of the bill yourself.
There are many doctors and hospitals out there. Insurance companies, as part of their efforts to keep costs down, work closely with many hospitals and physicians to help get you access to quality, affordable care, when you need it.
When you use an in-network provider, you’ll generally benefit by:
- Gaining access to discounted rates that often result in lower costs for you
- Paying a lower deductible, meaning the amount you must pay before your insurance begins to pay
- Paying lower out-of-pocket costs, meaning any medical payments other than the insurance premium you are responsible for and for which you won’t be reimbursed
- Having preventive services that are covered at little or no cost to you
Here’s an example: If you go to an in-network and have a $20 copayment, but the the doctor’s actual charges are $150, you will only have the pay the $20 copayment. But, if you went to a doctor out of your plan’s network, your share of the cost would likely be much higher.
PPO vs HMO: What’s The Difference?
When it’s a medical emergency or you can’t wait for a doctor’s office to open, go to the nearest hospital or urgent care. In or out of network, almost all plans help pay for medically necessary emergency and urgent care services.
When it’s not an emergency, PPO and HMO plans work differently.
HMO plans don’t include out-of-network benefits. That means if you go to a provider for non-emergency care who doesn’t take your plan, you pay all costs.
PPO plans include out-of-network benefits. They help pay for care you get from providers who don’t take your plan. But you usually pay more of the cost. For example, your plan may pay 80 percent and you pay 20 percent if you go to an in-network doctor. Out of network, your plan may 60 percent and you pay 40 percent.
Beware Of Surprise Billing
When we talk about in and out of network, it is important to warn you about surprise billing. This is when certain provider groups practicing at in-network hospitals stay out-of-network. This is generally done when providers know patients have no choice but to see them for care: for example, the emergency room or your anesthesiologist during surgery. Just because you are at an in-network hospital, that doesn’t mean the doctor seeing you will be in-network.
To avoid surprise billing, check with the provider(s) and hospitals on who will be giving you care and if they are in-network.
The Bottom Line
Whenever you’re facing surgery or any health issue, it’s always a good idea to check on the status of your provider(s) before you receive care. And of course, if you’re facing a medical emergency, visit the nearest urgent care center or emergency department. It’s also a good idea to get familiar with your insurer’s guidance on whether to visit the ER or go to urgent care.
If you’re curious whether your doctor is in-network or not, your insurance company should have an online lookup tool that you can utilize or you can simply call or email their customer service for information concerning your plan.