What the Guidance Really Says About In-Network and Out-of-Network Care

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.

What it is

The difference between doctors, hospitals and pharmacies that have a contract with your plan and those that do not. It sits within Health Insurance. The figures below are the ones published guidance uses, rather than the ones that circulate.

The numbers, in one place

What helps

These are the changes with the clearest evidence behind them. Start wherever it is easiest to start.

• 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

What to avoid

What to steer clear of, and why it catches people out.

• 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

In depth

A health plan's network is the group of doctors, hospitals, labs, pharmacies and other providers that have signed contracts with the plan. In those contracts, providers agree to accept negotiated rates for covered services, and agree not to bill you for more than your share of that rate. That agreement is what makes in-network care predictable: you pay your copay, coinsurance or deductible based on the negotiated rate, and the provider writes off the rest.

Out-of-network providers have no such contract. Depending on your plan, the plan may pay nothing, or may pay part of what it considers a reasonable amount for the service. In some situations, the provider can then bill you for the difference between their full charge and what the plan paid. This is called balance billing, and it is why out-of-network care can cost far more than you expect, even when your plan says it covers out-of-network services.

Federal law now limits several of the most common surprises. Under the No Surprises Act, emergency services and certain non-emergency care from out-of-network providers at in-network hospitals and surgery centers are limited to in-network cost-sharing. But for most planned care you choose yourself, checking network status in advance is still your best protection. Networks also change, so a provider who was in network last year may not be this year.

Signs and symptoms

• A bill much higher than you expected for a covered service
• An EOB showing "out of network" or a lower plan payment
• A provider asking for full payment at the time of service
• A claim denied because the provider is not in your network
• A notice asking you to give up your surprise billing protections

Causes and risk factors

• Plans with narrow networks to keep premiums lower
• Providers joining or leaving networks each year
• Seeing a doctor recommended by someone on a different plan
• Travel or moving outside your plan's service area
• Using a lab, imaging center or specialist chosen by another provider
• Directory listings that are out of date

How it is checked

To check whether a provider is in network, use your plan's online directory, then call the provider's office and ask whether they are in network for your specific plan, not just the insurance company. Many insurers offer several plans with different networks. For hospitals and large groups, confirm that the specific location and the specific clinician are in network.

Federal rules require plans to keep directories up to date. If you rely on incorrect directory information showing a provider as in network, and the provider turns out to be out of network, your plan generally can only charge you in-network cost-sharing. Keep a screenshot or note of the listing and the date you checked, along with the name of anyone you spoke to.

Treatment and support options

Choose a plan with your providers in it

If you have doctors you want to keep, check that they are in network before choosing a plan during open enrollment. HMO and EPO plans often have lower premiums but cover little or nothing out of network except emergencies. PPO plans usually cost more but cover some out-of-network care. A plan is only good value if the providers you need are in it.

Check every provider for planned care

For surgery or a hospital stay, ask who else will be involved, such as an anesthesiologist, radiologist, pathologist, assistant surgeon or lab, and whether they are in network. Federal law protects you from surprise bills from many of these providers at in-network facilities, but asking in advance avoids disputes and helps you understand what you will pay.

Ask about continuity of care

If your doctor leaves your plan's network while you are in active treatment for a serious condition, pregnant, scheduled for surgery or receiving certain other ongoing care, you may be able to continue seeing them at in-network rates for a limited time. Ask your plan about continuity of care as soon as you receive notice that your provider is leaving.

Request a network exception

If no in-network provider can provide the care you need within a reasonable distance or time, you can ask your plan to cover an out-of-network provider at in-network rates. Your doctor can support the request by explaining why the specific expertise is needed. Get the approval in writing before the care, if possible.

Prevention

• Check network status before every new provider, lab or facility
• Recheck your doctors' network status each open enrollment
• Ask whether the doctor and the location are both in network
• Keep records of directory checks and calls
• Ask your doctor to send labs and imaging to in-network facilities

Day to day

Staying in network becomes routine once you know your plan. Keep your plan's app or directory bookmarked, and when a doctor refers you elsewhere, ask the office to choose an in-network option. Many referral offices will do this if you ask, but they may not know your specific plan unless you tell them. Bring your insurance card to every visit so the right plan details are on file.

When you do get an out-of-network bill, do not pay it immediately. Compare it with your EOB, check whether the No Surprises Act applies, and call your plan. If you went out of network by choice, ask the provider for a discount, a self-pay rate or a payment plan. Many providers will negotiate, especially if you ask before the bill goes to collections.

For specific groups

Medicare Advantage members

Medicare Advantage HMOs usually require you to use network providers except in emergencies, while PPOs allow out-of-network care at higher cost. Original Medicare does not use networks; you can see any provider that accepts Medicare.

College students and people who travel

If you live in a different area from your plan's main service area, the network there may be limited. Check before moving whether your plan has providers near you, or whether a different plan, such as a student health plan, would work better.

People with rare conditions

If you need a specialist with rare expertise, the nearest one may be out of network. Ask your plan about network exceptions or single-case agreements, and have your doctor document why that specialist is needed.

Questions to ask your doctor

• Are you in network for my specific plan, not just my insurance company?
• Which lab, imaging center and hospital do you use, and are they in my network?
• Who else will be involved in my procedure, and are they in network?
• Can you refer me to an in-network specialist?
• If you leave my network, how will my care continue?
• Will you support a network exception request if I need it?

More questions, answered

What is balance billing?

Balance billing happens when an out-of-network provider bills you for the difference between their full charge and what your plan paid. In-network providers cannot do this. The No Surprises Act bans balance billing in many emergency and in-network facility situations.

What if my plan's directory was wrong?

If you relied on a directory listing showing a provider as in network, federal rules generally limit you to in-network cost-sharing. Keep evidence of the listing, contact your plan, and ask it to correct the claim.

Is out-of-network emergency care covered?

Yes. Plans must cover emergency services at out-of-network emergency departments without prior authorization, and your cost-sharing is limited to in-network amounts. Most out-of-network providers cannot balance bill you for emergency care.

What is the difference between HMO, PPO, EPO and POS plans?

HMOs usually require a primary care doctor and referrals, and cover only in-network care. EPOs cover only in-network care but often do not require referrals. PPOs cover some out-of-network care. POS plans mix HMO and PPO features, often requiring referrals.

Can I see an out-of-network doctor if I want to?

Yes, but you may pay much more, or the full cost, depending on your plan. If your plan covers some out-of-network care, ask the provider for an estimate and check what your plan will pay before your visit.

Are pharmacies part of the network?

Yes. Plans have pharmacy networks too, sometimes with preferred pharmacies that offer lower copays. Using an out-of-network pharmacy may cost more or not be covered. Check your plan's pharmacy list or app.

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

• New to In-Network and Out-of-Network Care? Start Here
• In-Network and Out-of-Network Care: The Questions People Actually Ask
• 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.