Employee Benefits
In-Network vs. Out-of-Network Healthcare Providers: What’s the Difference?
When you enroll in health or dental insurance, you receive an insurance card insurance card that provides information about your coverage. Insurance cards often include information about “in-network” and “out-of-network” healthcare providers. What do these terms mean, and how can they affect your coverage, and your cost? Let’s take a closer look.
What does in-network and out-of-network mean?
A network is a group of healthcare providers. When an insurance company partners with a provider, like a doctor or a dentist, that provider agrees to a negotiated — i.e., discounted — rate for services provided to the member. This provider is an in-network provider.
When a provider doesn’t partner with your insurance company, your insurer is charged the full price for their services, raising your expenses as well. This is an out-of-network provider.
How do in-network vs. out-of-network providers work?
The key difference between in-network and out-of-network benefits is the amount you’ll pay a provider for service.
Let’s say you’re experiencing tooth pain and decide to see an in-network dentist. In this case, your insurance company is charged the lower negotiated price for service, and you’re likely responsible for a copay and/or a percentage of the cost, depending on the type of insurance you have. Your out-of-pocket costs (copays and/or percentage of costs) are typically based on discounted services and lower than fees for out-of-network providers.
So when choosing a dentist to visit, selecting an in-network provider if possible will help you keep more money in your pocket. Learn more about finding in-network providers.
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What are in-network vs. out-of-network rates?
For most policies, you’re responsible for paying a predetermined percentage of any medical bills you incur. For example, with an in-network provider, that could be 20% of the bill, while an out-of-network provider could cost between 40% and 60%.
To better understand how out-of-network vs. in-network costs work, imagine you get sick and have to be hospitalized for three days. Your hospital costs might look something like this:
Cost of hospital stay |
Percentage covered by insurance |
Your responsibility |
|
In-network |
$12,000 (discounted in-network rate) |
80% | $2,400 |
Out-of-network |
$20,000 (full price of service) |
60%
|
$8,000 |
In this example, you could save over $5,000 on the cost of your stay by choosing an in-network hospital. Of course, depending on your specific plan details, costs will vary.
Why would someone choose to use an out-of-network provider?
There can be situations when an individual chooses to use an out-of-network insurance provider, even if it’s not the most cost-effective option. Here are a few examples of when that may be preferable:
- Specialized expertise: An out-of-network provider may have unique skills and experience treating a specific condition or performing a certain procedure. Opting for this service could ensure you receive the best possible care for your needs.
- Geographic accessibility: In rural or remote areas, there may be limited options for in-network providers. You may need to use an out-of-network provider to receive timely and convenient care.
- Continuity of care: You may want to continue seeing a healthcare provider that you have an established relationship with, even if they’re no longer within your network. This can be particularly beneficial if you’re managing a long-term medical condition.
How do you find in-network providers?
A simple internet search may be all it takes to locate which providers are within your insurer’s network. Here are a few suggested sites to help you get started.(Note that it’s a good idea to verify participating providers directly with your insurance company before you schedule a service).
Your insurance company’s website: Your insurance company most likely has a list of providers operating in-network. This is the easiest place to start your search.
Your healthcare provider’s website: Likewise, doctors, hospitals, dentists, and other healthcare providers often include a list of participating insurance plans on their website. This will let you know whether you can visit them at the in-network rate.
An online healthcare platform: You can also try using an online healthcare site to find and book in-person or virtual appointments with in-network providers.
How supplemental health insurance may help
If you or a loved one are involved in an emergency, it’s unlikely that you’ll be able to choose an ambulance service you use or a hospital. The priority is to get you to the nearest medical facility, even if that means using an out-of-network provider.
Supplemental health insurance can help provide valuable assistance in covered situations when your primary health insurance policy doesn’t cover all your medical expenses. For example, hospital indemnity insurance provides payments for covered incidents that can be used to help cover hospital visits and unforeseen emergencies. Additionally, accident insurance typically provides a lump-sum cash benefit that can be used to cover medical expenses — including out-of-network costs — in the event of a covered accident.
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This article is intended to provide general information about insurance. It does not describe any Metropolitan Life Insurance company product or feature.