What is a network?
A network is a group of providers - doctors, hospitals, and other health care professionals - that have entered into agreements with health plans to treat their members at discounted rates. The health plan will pay a larger percentage of your covered health expenses when you use providers in its network. Therefore, you'll have lower out-of-pocket costs if you stay in the network. Also, your costs for in-network services are predictable since the provider and your health plan have negotiated the charges in advance. If you use providers that aren't in your network, you might have to pay the full cost of your care yourself.
An in-network provider is also called a preferred provider.
Where is the Preferred Provider List?
Balance billing -- or surprise medical bills -- happen when you get health care outside of your plan's network. Out-of-network providers haven't agreed to treat a health plan's members at discounted rates. Therefore, their rates are higher than the rates negotiated between a health plan and its preferred providers. Even if your health plan pays for some out-of-network services, it will only pay the allowed amount as determined by the insurer's selected methodology. You will have to pay the difference between what your plan will pay and what the out-of-network provider charges you. This is called balance billing. Out-of-network providers can bill you for these charges; preferred providers cannot.
There are some exceptions. In an HMO or EPO, you typically won't have to pay any balance-billed charges if you received out-of-network care because of a medical emergency or if there weren't any preferred providers available to treat you. In a PPO, you may be balance billed even for emergency services, but your expenses will count toward your in-network deductible and out-of-pocket maximum. If your balance-billed charges from a hospital-based provider are more than $500, you may request mediation.
For more information, visit the Avoiding Surprise Bills page.
Do all plans have the same rules for networks?
HMOs & EPOs
Health maintenance organizations (HMOs) and exclusive provider organizations (EPOs) may limit coverage to providers inside their networks. If you go out-of-network under an HMO or EPO, except in an emergency or if services aren't available from preferred providers, the HMO or EPO may pay nothing. In an HMO, you usually have to choose a primary care doctor and have to get referrals to see specialists. However this is generally not true for EPOs. These are sometimes referred to as "narrow network" plans because your choice of providers may be more limited.
Learn about your rights in an EPO plan
PPOs & POS plans
Preferred provider organizations (PPOs) and point-of-service plans (POS plans) don't limit coverage to preferred providers. They will pay for some out-of-network costs but will pay more if you stay in-network. These networks tend to provide more choice among providers than HMOs and EPOs. In a PPO, you can visit any provider without a referral. In a POS plan, you can visit any preferred provider without a referral but you will need one to visit an out-of-network provider.
Learn about your rights in a PPO plan | Learn more about comparing plan types
Understand the Plan's Network
It's important to understand a plan's network to avoid unnecessary costs:
- understand the rules and protections associated with the plan type (preferred provider organization, exclusive provider organization, HMO, point of service plan)
- search the preferred provider directory to see which doctors are available in any specialty category you think you might need
- look at the plan disclosures to see if the plan has an adequate network in your area, or whether the plan has an active local market access plan for any provider area of practice
- use the preferred provider directory to identify whether the in-network hospitals near you have agreed to help assign preferred providers to your care
- for a preferred in-network hospital, look at how often an insurer's enrollees get care from out-of-network providers
- understand the methodology the plan uses to develop an allowed amount used to pay nonpreferred providers
Favorable insurer networks:
- have network coverage that meets your needs
- include any providers you wish to work with
- include high quality providers
- minimize your risk of balance billing by facility-based providers
- mitigate balance billing by establishing fair allowed amounts for nonpreferred providers
For more information contact:
Last updated: 05/03/2016