Typically, we purchase a health insurance plan that is accepted by our family doctor or preferred primary healthcare provider (PHP), assuming we already have one. For most of us this simply means we don’t need to worry about whether that office will accept our insurance.

In fact, that concern usually only comes up when we find ourselves out the area, out of state, or maybe even out of the country. If we need to see a doctor then, what do we do since we don’t know if our coverage is accepted by any nearby doctor?

Fortunately, in most cases, you can be seen by a doctor who is “out-of-network” and your insurance may still offer a limited amount of coverage.

According to an explanation offered by Blue Cross/Blue Shield,

“When a doctor, hospital or other provider accepts your health insurance plan we say they’re in network. We also call them participating providers. When you go to a doctor or provider who doesn’t take your plan, we say they’re out of network. The two main differences between them are cost and whether your plan helps pay for care you get from out-of-network providers.”

In-Network and Out-of-Network Providers

Let’s take this concept a bit further.

An in-network provider, also known as a “contracted provider” is contracted with a health insurance company to provide services to plan members of that company for specific pre-negotiated rates. Be aware that even though some providers in your area may accept your insurance they are not necessarily an in-network provider.

If they are, in fact, an out-of-network provider, this simply means that they not contracted with your health insurance plan. Most of the time Typically, the amount you will be responsible for paying if you visit a physician or other provider within your network, you will pay far less than if you visit an out-of-network provider.

In fact, while they are often exceptions, most of the time your insurance company will either pay less for the billed service or pay nothing at all for services you receive from out-of-network providers.

Generally speaking, PPO, POS, and HMO health plans work with contracted provider networks and will encourage you to use those providers.

VerywellHealth.com points out,

“Some health plans, like HMOs and EPOs, do not reimburse out-of-network providers at all (except in emergency situations), which means that as the patient, you would be responsible for the full amount charged by your doctor if they’re not in your insurer’s network. Other health plans offer coverage for out-of-network providers, but your patient responsibility would be higher than it would be if you were seeing an in-network provider.”

How to Use the Ease Program to Manage your Health Insurance Policy 

Why Your Current Doctor May be Out-of-Network

There can be any number of reasons why your doctor is not in the network of your new health plan, but the most common reason is that he or she did not want to take the insurer’s negotiated rates.

At other times, it is because the insurance provider wants to have a relatively small network that allows it to have a stronger position when negotiating with healthcare providers. Because of this, it may be that your doctor is willing to join the network, but the insurer doesn’t have any network openings available for the services that your doctor provides.

Because this type of arrangement can lend itself to unfair practices, there is legislation in place to help prevent that from occurring. In fact, many states have passed “any willing provider” laws that prevent insurers from blocking providers from the network, if the healthcare provide is willing and able to meet the insurer’s network requirements.

Because individual states can establish “any willing provider” rules for health plans that are regulated by those states, all self-insured plans, that is, those typically used by very large insurers, are under federal regulations instead of state regulation, which means that the “any willing provider” rules don’t apply to those plans.

Examples of Common Out-of-Network Scenarios

As we noted at the start of this post, If you need to see a doctor or receive medical care while you’re away from home, you may have to go out of network. Fortunately, some insurers will handle your claim for a visit to an out-of-network provider as if it were and in-network visit.

In an emergency, you must usually go to the closest available medical facility. Fortunately for the patient, The Affordable Care Act (ACA) requires insurers to cover emergency care as if it’s in-network, regardless of whether the emergency care is obtained at an in-network or out-of-network facility. However, the out-of-network emergency room and physicians may send you what is known as a balance bill, which is not restricted by the ACA, although California law does require health plans to cover the cost of the emergency care most patients receive regardless of whether a hospital is in-network or not.

If you suffer from a medical issue which requires specialized care, and no specialist is included in your plan, out-of-network care may be required.

The ACA also requires health insurers to maintain provider networks that are adequate based on the distance and time members must travel to a medical provider. For example, if you live in a rural area and you’re not within a reasonable distance of an in-network provider, you may be dependent on a non-participating doctor for your healthcare needs.

Because natural disasters such as flooding or widespread wildfires can destroy medical facilities or force people to evacuate to other areas, in-network medical care may not be available. In some instances, patients may be eligible for in-network rates as part of a declaration of emergency by the state or federal government.

Update April 19, 2024

When it comes to health insurance, understanding the difference between in-network and out-of-network providers can save you from unexpected costs. In-network providers have negotiated rates with your insurance company, meaning you’ll typically pay less for their services. However, if you find yourself seeing an out-of-network provider, your insurance may still offer partial coverage, but be prepared for higher out-of-pocket expenses.

But why might your preferred doctor be out-of-network? One common reason is that they didn’t agree to the negotiated rates with your insurer. Alternatively, your insurer might have a limited network, or your doctor may not have available network openings. Legislation like “any willing provider” laws aims to prevent unfair practices, ensuring patients have access to a broader range of providers.

Emergencies and specialized care are common scenarios where you may need to visit an out-of-network provider. The Affordable Care Act requires insurers to cover emergency care as if it’s in-network, offering some relief during critical situations. However, it’s essential to be aware of potential balance bills and coverage limitations, especially when receiving specialized care or facing natural disasters that disrupt local medical facilities. By understanding your coverage and seeking guidance when needed, you can navigate the complexities of health insurance with confidence and ensure you’re prepared for any healthcare situation.

JC Lewis small business insurance