When you first enroll in health or dental insurance, you may notice different costs for “in-network” and “out-of-network” healthcare providers. These terms refer to the scope of your insurance plan’s provider network, which is made up of the doctors, dentists, and other professionals who are contracted to work with your insurance company.
The largest difference between in-network and out-of-network benefits is the amount you’ll pay a provider for service.
What does in-network mean?
A network is a group of healthcare providers. When an insurance company partners with a provider, that provider agrees to a negotiated (i.e., discounted) rate for services provided to the member. This is called an in-network provider.
What does out-of-network mean?
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 called an out-of-network provider.
How do in-network vs. out-of-network providers work?
Let’s say you’re experiencing tooth pain and decide to see a dentist. When you choose which dentist to visit, you’ll want to make sure they’re an in-network provider if possible (more about finding in-network providers later).
If you choose to visit an in-network dentist, your insurance company is charged the lower negotiated price for service and you will likely be responsible for a copay and/or a percentage of the cost, depending on the type of insurance you have.
If you choose an out-of-network dentist, your insurance company is charged the full price of a visit and you are most likely responsible for a larger portion of the bill or a higher copay. The type of insurance you have will determine how much is covered and the dollar amount you’ll ultimately be responsible for.
HMO: your insurance company typically won’t cover any of the bill for out-of-network providers and you’ll have a copay for in-network care
Plan with coinsurance: the percentage of the bill you’re responsible for will be higher when using an out-of-network provider (e.g., 20% for in-network, 40% for out-of-network)
High deductible plans: your out-of-network deductible will be a separate, higher amount than that of your in-network maximum — you will be responsible for the full cost of care at a non-negotiated rate with out-of-network providers
What are in-network vs. out-of-network rates
Typically, you will be responsible for a predetermined percentage of any medical bills. For example, with an in-network provider, that could be 20%, while an out-of-network provider could be 40-60%.
To best understand how in-network vs. out-of-network rates 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
||$12,000 (discounted in-network rate)
||$20,000 (full price of service)
By choosing an in-network hospital, you could save more than $5,000 on the cost of one stay.
(Of course, depending on your specific plan details, these numbers will vary—this is just an imagined example.)
Why does out-of-network care cost more?
Out-of-network providers don’t have partnership benefits with your insurer and, therefore, will charge your insurance company (or you) the full price of service if you choose to visit them.
In-network providers partner with your insurance company to give patients a lower negotiated rate. In exchange, these providers are more likely to be frequented by people with coverage from that company.
How do you find in-network providers?
There are a couple of ways to find a provider within your insurance network:
Your insurance company’s website: Oftentimes, your insurance company will have a list of providers operating in-network. This is a surefire way to guarantee you’re going to a provider that’s covered.
Your healthcare provider’s website: Likewise, your doctor, hospital, dentist, or other healthcare provider will typically include a list of participating insurance plans on their website. This will let you know you can visit them at the in-network rate.
If you can’t find this information on your insurance or healthcare provider’s website, call your insurance company — they should be able to tell you who your participating providers are.