Employee Benefits

What’s the Difference? In-Network vs. Out-of-Network

in- and/or out-of-network

The terms “in-network” and “out-of-network” usually are mentioned along with insurance plan information. While these terms may sound confusing, not understanding them can result in paying higher out-of-pocket costs.

Sometimes people schedule an appointment with a health professional and may not realize that the professional is not listed as in-network with their insurance plan. If they’re not, the insurance company may cover only a small percentage of the cost.

Most insurance plans contract with specific health care providers in each market, such as general practitioners, specialists, hospitals, labs, diagnostic facilities or pharmacies, to accept a contracted fee for each covered service.

Here are a few other key points:

  • Ask your insurance company for a list of in-network providers
  • In-network providers will charge a contracted fee for covered services, but that does not mean your plan will cover 100 percent of the cost
  • If an in-network provider orders a procedure, do not assume the cost will be covered; verify coverage with your insurance company
  • Check plan description outlining covered services, as well as deductible and coinsurance requirements
  • Before scheduling an appointment or requesting a procedure, ask the provider if he/she is in your insurance plan’s network

If you decide to visit a medical professional not listed in the network, you may pay more for services. Since out-of-network providers have not agreed to contracted fees with your insurance company, the costs may be higher. Your insurance plan may also require a larger deductible and a larger coinsurance benefit toward out-of-network care.

Example of In-Network vs. Out-of-Network Charges

Here’s a simple example of in- and out-of-network payments for a procedure:

Service In-Network Out-of-Network
Test – charge $150 Network discount $50 Network discount $0
Balance $100 $150
Insurance coverage 80% of balance: $80 50% of balance: $0
Patient responsibility $20 $75

 

This example demonstrates how quickly health care costs can add up when services are provided by out-of-network professionals. To keep costs under control, ask providers whether they are under contract with your insurance plan before care is given. If they are not in the network, ask your insurance company or benefits representative how to obtain a list of current participating network providers.

Get more information about in- and out-of-network.

 

  • Deborah Hoskins ,

    I have the vision plan I want to know who the providers are in the Savannah,Ga area

    • Ameritas Insight ,

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