What does it mean when a doctor is out-of-network?

Navigating the world of health insurance can be confusing, and choosing a new health insurance plan or doctor can leave you with lots of questions, including:

  • What does out-of-network mean?
  • Will my doctor accept my new insurance plan?
  • How much will my appointment cost?

Knowing the answers can help you take charge of your health and ensure you have access to the care you need at an affordable price.

Find out more facts about choice in health care.

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The Difference Between “In-Network” and “Out-of-Network”

What is the difference between in-network and out-of-network care providers?

When a provider is in your network or “in-network” for you, it means they accept your health insurance plan. In-network providers generally have a contract with your insurance company, which means your insurance will pay for some or all of the services you receive from that provider. Usually, in-network providers and the insurance company have negotiated an approved (often discounted) rate for services, which can often make them a more affordable option for the insurance company and the patient.

A provider who isn’t contracted with your insurance company is referred to as “out-of-network,” meaning that provider does not have an agreement with your insurance company to receive payments at a negotiated rate. Depending on your plan, you may be responsible for all charges from that provider, so understanding which providers and facilities are in your network can be an important step in making health care choices.

Why choose an out-of-network provider?

In-network providers are usually more affordable, because you won’t have to pay as much out-of-pocket for your care. However, you might need to choose an out-of-network provider, perhaps due to medical issues while traveling or a natural disaster.

PPO (Preferred Provider Organization) and HMO (Health Maintenance Organization) plans usually cover in-network and out-of-network emergency care, so you can go to the nearest hospital without worrying about the cost.

But if these hospitals and physicians are out-of-network, your insurance plan may not cover your care after the “emergency” is over, such as in the case of a hospital admission or observation after you are stabilized.

You might also consider an out-of-network option when your preferred provider is out-of-network under your insurance plan. This can also be a choice if your provider leaves your insurance plan’s network but you’d like to continue seeing them for medical or personal reasons and choose to do so on an out-of-network basis.

What does out-of-network mean for appointment costs?

Generally, HMO and PPO insurance plans cover all emergency care after a deductible, whether the providers are in or out of network. Here’s the difference:

  • HMO plans: These generally do not include out-of-network benefits if the situation is not an emergency. This means that you’ll need to pay most — if not all — of your health care expenses out of pocket for out-of-network care.
  • PPO plans: Most of these do include visits to out-of-network providers. Although they won’t pay the entire bill, many will cover anywhere from 60 to 80 percent of the total cost.

If you plan to see an out-of-network provider within the next year, you may want to consult your health insurance company directly. If a number of your preferred providers are, or will be, out-of-network for you,  you may want to consider making changes to your plan during your next open enrollment period.

What if I prefer UPMC doctors and hospitals, but I have Highmark health insurance?

The recent agreement between UPMC and Highmark provides most Highmark members with full, in-network access to all UPMC doctors, hospitals, and services in the greater Pittsburgh and Erie areas. For questions, please call our help line at 1-855-646-8762.

How do you know if a provider is in-network or out-of-network?

The most effective way to ensure that your care will be considered in-network is to verify with the provider’s office or contact your insurance company. Some visits may even require prior authorization.

Now that you understand the difference between in-network and out-of-network coverage, you can learn more about your health insurance options.