In-network vs. Out-of-network Care

What is a network?

A network (also called provider network or preferred providers) is a group of medical providers (hospitals, doctors, specialists, pharmacies, etc.) that have contracted with an insurance company to provide medical care at an agreed-upon rate.

What is in-network vs. out-of-network care?

In-network care is medical care obtained from a provider within your plan’s network.

Out-of-network care is medical care obtained from providers outside of your plan’s network.

But, what does it all really mean?

What happens if I get out-of-network medical care?

It depends on the specifics of your plan.   While health insurance plans are not required to cover any out-of-network care, many do, at least to some extent.

Here are some things that may happen if you do receive care from out-of-network providers:

• Out-of-network care may not be covered at all, meaning you will be responsible for 100% of the cost.
• You may pay more for out-of-network care because it is covered at a lower rate than in-network care.  For example, you may pay 20% of in-network charges, vs. 40% for out-of-network charges.
• There may be a separate deductible for out-of-network care.
• The out-of-network deductible may also be higher than the in-network deductible.
• Out-of-network care may not be counted toward your annual maximum out-of-pocket limit.
• Out-of-network providers are not required to accept a contracted rate, so you may be balance-billed for some expenses over and above any covered amount.

What happens if I had no choice but to get out-of-network care?

There may be some circumstances which require out-of-network care.  For example:

• You wanted to visit a particular professional or facility for a specific covered treatment or service that was not available in your network.
• You inadvertently got out-of-network care while hospitalized in an in-network facility because one of the physicians working in the hospital (e.g. anesthesiologist, radiologist, etc.) did not participate in your plan’s network.
• You received emergency care at an out-of-network facility.

If one of these situations occurs, you can appeal the decision of your insurance company.  This is where having the assistance of a broker can really come in handy.

This kind of thing really does happen.  Click here to read a real-life situation encountered by one of our clients.

How can I protect myself from expensive, out-of-network care?

The very first line of defense is knowledge!  When purchasing coverage, make sure you know exactly what doctors, pharmacies, hospitals, and other medical facilities are part of the network for any plan you are considering.  And, make sure you understand each plan’s rules regarding use of out-of-network providers.

Once you are covered, when seeking care, always ask if a provider is part of your plan’s network — before obtaining care!

Virginia Medical Plans helps our clients understand and select the best health insurance for their needs.  Give us a call or email!