Knowing the difference could help you save money on health insurance.
Depending on your health insurance, your plan may show different prices for in-network providers and out-of-network providers. What’s the difference—and how do you know if a provider is “in-network?” It’s important not to shrug off this detail on your insurance plan because knowing the difference could help you save money.
What Is a “Provider?”
Provider is a health insurance term for any facility, supplier, or professional for healthcare services. Examples of a provider include:
- Urgent care facilities
- Dental offices
- Therapy clinics
- Oxygen therapy supply companies
- Diabetes supply companies
- An individual doctor, therapist, dentist, etc.
In-Network Providers for Health Insurance
Health insurance companies have contracts with certain providers. This means the provider will offer their services at a discounted price. A provider who has a contract with your insurance company is called an in-network provider (or sometimes a “preferred provider”). Those who don’t are an out-of-network provider.
You can often save money by sticking to in-network providers, depending on your insurance plan. Your plan might charge you extra for using an out-of-network provider, or they might not cover the service at all. For example:
- PPO plans and POS plans generally allow you to see out-of-network providers, but at an extra cost. This may exclude emergency services. In other words, you’d pay less by seeing an in-network provider.
- HMO plans and EPO plans generally do not cover services from an out-of-network provider at all (except for emergency care). This means you might end up paying full price.
Remember, many plans do not differentiate between in-network and out-of-network providers for emergency care. If you’re having an emergency (like a heart attack, stroke, or major injury), it’s best to go to the nearest medical facility. Don’t waste time searching to find an in-network emergency department. Get familiar with your plan’s emergency care coverage so you can know what to do if a serious health issue arises.
Finding an In-Network Provider for Your Insurance
How do you know if a doctor, clinic, or supplier is in your plan’s network? There are a few ways to check.
First, you can often find providers in your area by searching on your insurance company’s website. Often, these sites offer a “Find a Provider” feature. You can typically filter by what type of provider you’re looking for (such as a dentist, psychologist, or primary care doctor). You can also often narrow your search by gender, location, and specialties.
Another option is to check the provider’s website. Often, these sites will list which insurance plans they “accept.” If your plan is listed, this typically means they are in-network for your plan.
The third option is always a good idea: Call the provider directly to confirm they accept your plan. Contracts between providers and insurance companies may change from time to time, and the websites aren’t always up to date. Even if a provider’s website says they accept your plan, it’s best to call and make sure that information is still accurate. Otherwise, you might end up with a surprise bill later that’s higher than you expected (and nobody wants that).
What If There Aren't Any In-Network Providers In Your Area?
In a few cases, you may live in an area where there are no in-network providers for the service you need. For example, you may not have any therapists or gastroenterologists in your immediate area who accept your insurance. In this instance, your insurance may allow you to see an out-of-network provider at an in-network cost. However, this is made on a case-by-case basis. Always contact your insurance ahead of time to learn about your options.
Want to save more money on your health insurance plan? Check out these tips to make the most of your health insurance.
- Health insurance plan & network types: HMOs, PPOs, and more. Washington, DC: HealthCare.gov. (Accessed on July 20, 2021)
- In-network copayment. Washington, DC: HealthCare.gov. (Accessed on July 20, 2021)
- Network. Washington, DC: HealthCare.gov. (Accessed on July 20, 2021)
- Preferred provider. Washington, DC: HealthCare.gov. (Accessed on July 20, 2021)