In-Network and Out-of-Network Care: The Quick Reference
In-Network and Out-of-Network Care: the whole thing in five minutes, for when you want the numbers and nothing else.
The difference between doctors, hospitals and pharmacies that have a contract with your plan and those that do not.
Key takeaways
- In-network: providers that have agreed to set rates with your plan
- HMO and EPO plans: generally cover only in-network care except in emergencies
- Most useful single change: Check the plan's online directory and call the provider to confirm they are in network.
- Commonest mistake: Assuming a provider is in network because a friend on a different plan sees them.
- See a doctor if any of the signs under "When to speak to a doctor" below apply to you.
The numbers, in one place
| Measure | Figure |
|---|---|
| In-network | providers that have agreed to set rates with your plan |
| HMO and EPO plans | generally cover only in-network care except in emergencies |
| PPO and POS plans | may pay part of out-of-network care, usually at a higher cost to you |
| Balance billing | when an out-of-network provider bills you for the difference between their charge and what the plan pays |
| Emergency care | federal law limits what you pay for out-of-network emergency services |
In one paragraph
Out-of-network care usually costs you much more, and in some plan types it is not covered at all except in an emergency.
Worth doing
- Check the plan's online directory and call the provider to confirm they are in network
- Ask whether the specific location, not just the doctor, is in network
- Find out if your plan needs a referral before you see a heart, skin or other specialty doctor
- For planned surgery, ask whether the surgeon, anesthesiologist and lab are all in network
Worth avoiding
- Assuming a provider is in network because a friend on a different plan sees them
- Relying on an old directory listing; networks change from year to year
- Avoiding the nearest emergency room because you are unsure of its network status
Related topics
- The Evidence on Medicare Advantage Plans, Without the Hype (Medicare and Medicaid)
- Choosing the Right Care: What Published Guidance Supports (Preventive Care)
- What the Guidance Really Says About When to Go to the ER (Using Health Services)
- Sexual Health Services: What Published Guidance Supports (Sexual Health)
Where to go next
- In-Network and Out-of-Network Care: Common Myths and What Guidelines Say
- New to In-Network and Out-of-Network Care? Start Here
- In-Network and Out-of-Network Care — the reference entry
- Health Insurance: The Complete Guide
- What the Guidance Really Says About Reading an Explanation of Benefits
- No-Cost Preventive Care: What the Evidence Actually Says
When to speak to a doctor
In a medical emergency, call 911 or go to the nearest emergency room; do not search for an in-network hospital first. If you get an unexpected out-of-network bill, contact your plan before you pay it.
Where this comes from
- HealthCare.gov — Health insurance plan and network types
- CMS — No Surprises: Understand your rights against surprise medical bills
How this page was put together
Every figure, recommendation and warning above is taken from the guidance named in Where this comes from. Nothing on this page is inferred, summarized or generalized beyond what those bodies publish: where they give a number, it is their number, and where they are silent, so are we. Pages are rebuilt whenever the underlying record changes. Sign-off by a named clinician, where it has happened, is shown at the top of the page along with the date.
Medical disclaimer
This article is general information, not medical advice. It cannot account for your own history, medication or circumstances. Always speak to your doctor, pharmacist or another qualified health professional before making changes that affect your treatment, and never delay seeking medical advice because of something you have read here. In an emergency, call 911.
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