By: Maddie Rogerson, Account Manager-Patient Finance Office
Last month in the first installment of our 12-part “Understanding your Insurance” series, we discussed the top 3 things you need to know about health insurance coverage. This month, we will be discussing what it means when a provider is in-network versus out-of-network, as well as the best way to find out if a provider is in-network or out-of-network.
Here are the top 3 things you need to know:
1. What does it mean to see an “in-network” provider?
In-network providers are part of your health plan’s network of providers, meaning the provider and your health plan have negotiated a discounted rate for the medical costs incurred at the provider’s office. For example, you go to a doctor that is in-network. The negotiated rate is then applied. Then depending on your plan, your deductible will apply and you’ll pay the remainder. If you have met your deductible, your insurance will then pay their portion. This amount again depends on your plan. In this example you have a 20% coinsurance.
Deductible Not Met
| Total Billed Amount | Discount Amount | Insurance Portion | Your Portion |
| $250.00 | $75.00 | $0.00 | $175.00 |
Deductible Is Met
| Total Billed Amount | Discount Amount | Insurance Portion | Your Portion |
| $250.00 | $75.00 | $125.00 | $50.00 |
2. What does it mean to see an “out-of-network” provider?
Out-of-network providers are not part of your health plan’s network of providers; therefore the negotiated discount does NOT apply. Depending on your individual health plan, you may or may not have out-of-network benefits. Health plans, like HMOs and EPOs, do not reimburse out-of-network providers at all, which means that as the patient, you would be responsible for the full amount charged by your doctor. Some plans do have out-of-network benefits which means expenses incurred will be covered, but the negotiated rate will not apply. Also, this type of plan may require higher co-pays, deductibles and co-insurance for out-of-network care. So, if you normally have to pay 20% of the cost of the service in-network, you may have to pay 30% out-of-network.
3. What is the best way to find out if a provider, urgent care, emergency care is in/out-of-network?
Go directly to your insurance carrier’s website and search the provider directory by entering in the provider’s name and details. If your provider’s name pops up, that’s a good indication they accept your plan and they are in your plan’s network. Keep in mind, sometimes information on a carrier’s look up tool is outdated, so you can always give your insurance company a call and verify. Out-of-network emergency care is covered under all insurance plans sold after March 23rd, 2010 as part of Ten Essential Benefits under the Affordable Care Act. Insurance plans can’t require higher copayments or coinsurance if you get emergency care out-of-network and they cannot require prior approval either. Keep in mind, all non-emergency care must be done in-network to be covered and may require prior approval.
While these 3 items are important in understanding what provider is most cost effective for you, then next thing you must keep in mind is what your plan specifics are. Next month we will look at the differences of deductibles, co-pays, and co- insurance.
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