Why Do Some Plans Cover Benefits From Network Providers, But Not Out-of-Network Providers?

Patient Resources

When you are shopping for coverage, you might be wondering why some plans cover benefits from network providers but not out-of-network providers. While the two types of providers aren’t exactly similar, there are significant overlaps between them. An out-of-network provider is a doctor or other healthcare professional who services patients that your plan does not have in their network. A network provider is any doctor or other healthcare professional who services patients that your plan does have in its network. In order of frequency, the major differences between an in-network provider and an out-of-network provider include the following:

What Is an In-Network Provider?

An in-network provider is a doctor, hospital, or another healthcare professional who primarily services people enrolled in your plan. If you need treatment from someone outside your plan’s in-network network, you may be out of luck. You’re not necessarily covered if you choose to see an out-of-network provider. You may, for example, be charged higher fees. But that’s often up to your insurance company.

What Is an Out-of-Network Provider?

An out-of-network provider is a doctor or other healthcare professional who primarily services people not enrolled in your plan. You may have the option to see this provider, but you may have to pay higher out-of-network rates or be charged higher co-pays or other charges. You may have the option to see this provider, but it may take longer to get an appointment. You may have the option to see this provider, but there’s a chance you won’t be able to get the treatment you need.

Why Are Some Plans Covering Network Providers, But Not Out-of-Network Providers?

Some plans cover benefits from network providers but not out-of-network providers. In some cases, this may be because your plan’s network just happens to include a lot of in-network providers. In other cases, the plans may cover only a small number of providers. Most plans, for example, only cover hospitals and/or doctors within their network. Some plans may cover fewer providers, including a smaller network of specialists.

Which Network And Out-Of-Network Providers Do Your Plans Cover?

Each plan is different. Your best bet is to do a little digging on your own to find out which network and out-of-network providers your plan covers.

How To Find Network And Out-Of-Network Coverage For Your Healthcare Needs

If you need help finding which network and out-of-network providers are covered by your plan, ask your insurance provider’s representative. (This information should be available to you in your Insurance provided ID card) You may also be able to find out your plan’s network and out-of-network coverage through your state’s insurance department website.

Bottom Line – Be Careful When You’re Choosing Coverage

If you don’t understand your plan’s coverage and how it compares to other plans, you could wind up paying more. Make sure you’re clear on your plan’s network and out-of-network benefits.

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