In-Network vs. Out-of-Network – What it Means and Why it's Important
By Kara Miecznikowski and Jimmy McDermott
How to find out if your insurance will cover medical care from different healthcare professionals
In-network care will be significantly cheaper than out-of-network care in most places in the US. This article will explain how to find an in-network medical professional in order to keep healthcare costs down.
What is In-Network vs. Out-of-Network?
In-network health care providers – hospitals, doctors, dentists, specialists, pharmacies – have an agreement with an insurance company to provide medical care to their insured members at a discounted rate. This rate is agreed upon by the health care provider.
In contrast, “Out-of-network” health care providers do not have an agreement with your insurance company to provide care. While insurance companies may have some out-of-network benefits, medical care from an out-of-network provider will usually cost more out-of-pocket than an in-network provider.
How does it impact out-of-pocket expenses?
Obtaining health care services from a healthcare professional or facility that is in-network is generally (much) cheaper than out-of-network. This is because the functions of cost sharing – deductibles, coinsurance and copays – apply to health care services that are provided by in-network healthcare professionals and facilities under your insurance plan. Cost sharing may apply to out-of-network healthcare professionals to a reduced extent, or not at all: this means that you may be responsible for paying more or all of the medical care cost.
How much will out-of-network care cost?
The amount that a health care insurance plan will contribute toward out-of-network services will vary by your insurance company and is often based on a “reasonable and customary” amount that the service should cost. For example, if you go to an out-of-network dentist and are billed $300 for the service, your insurance company may contribute $200 toward paying this cost because $200 is the amount it has decided is “reasonable and customary” for this service.
When out-of-network, any remaining cost above this amount ($100 in this case) may have to be fully covered by the person receiving care. When out-of-network, the usual coinsurance rates that apply in-network may not apply out-of-network. Additionally, out-of-network service costs may not count toward your annual deductible.
How do you find out if you're in/out of network?
Many insurance companies have mobile apps that include a “Find a Doctor” feature for in-network healthcare professionals.
- Aetna: Aetna Mobile
- Anthem: Anthem Anywhere
- Cigna: myCigna
- Humana: MyHumana
- United Healthcare: Health4Me
A second option is to check your insurance company’s website or call a Members Services line and speak with an insurance plan representative. If provided, your member ID card may have a number and/or website to access for this information.
Below are links to the pages for finding an in-network healthcare professional for the main health insurers in the US:
- Medicaid: varies by state (visit your state’s Medicaid website)
- United Healthcare
You can also directly call a health care professional or facility and ask if it is in-network. In this case, it is important to make sure that it accepts your specific insurance plan, not just your insurance: different plans under the same insurer often have different terms.
In-network and out-of-network healthcare professionals may change over time, so you should regularly check to confirm that there have been no changes to your healthcare professional’s network status in order to avoid unexpected out-of-pocket costs. Similarly, an in-network healthcare professional may refer you to a specialist that is out-of-network: always check to ensure that any new healthcare professional is also included in your insurance plan coverage.
If you prefer a healthcare professional or facility that is out-of-network (or was in-network and is now out-of-network), you may choose to stay with this healthcare professional, depending on the cost. You can also consider switching plans or insurance companies that include this healthcare professional in their network, or have better out-of-network benefits.
This article is part of a series on access that was made possible by support from Lilly Diabetes and Novo Nordisk. The diaTribe Foundation retains strict editorial independence for all content.