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All About: Healthcare Provider Networks

What they are, how they work and why you should care

Written by: Aaron Garcia.

Older couple reviewing Medicare options and costs.

Key Takeaways

  • Provider networks are groups of doctors and hospitals that work with private insurance companies to provide care within a specific geography.

  • Provider networks determine which doctors you can see and how much you pay for care. Your plan and carrier determine if your doctor is in-network or out-of-network.

  • Health insuranceHealth insurance is a form of insurance that covers a portion of your medical expenses. In exchange, you pay a monthly premium and other costs. companies negotiate with doctors in their networks, which means you pay less for in-network services and more for out-of-network services.

Provider networks are groups of doctors, hospitals, and facilities that contract with private insurance plans. Your plan’s network dictates the doctors you can see and how much you pay for in-network care. We have answers and breakdown provider networks for you.

What are Provider Networks?

Provider networks are groups of doctors, specialists and hospitals that have a negotiated contract with a health insurance carrier. [1] A provider network should include coverage for the services in your explanation of benefits. Policyholders pay lower in-network rates than if they saw a provider out-of-network.

Does My Plan Have a Provider Network?

Yes, and knowing what stipulations it has depends on your health insurance plan type. Insurance companies categorize services provided by doctors and specialists as in-network and out-of-network. Your first choice should always be an in-network healthcare provider. You will receive more cost coverage for services in-network rather than out-of-network. Some plans, like HMOs, do not provide coverage for services deemed out-of-network.

Here is a list of plan types and how they use provider networks:

Health Maintenance Organization (HMO)

  • All providers must be in-network. Exceptions are typically granted only in emergencies.

Preferred Provider Organization (PPO)

  • PPO policyholders usually have a provider network but are allowed to visit out-of-network doctors and other specialists if they pay a higher price and file the claim themselves.

Exclusive Provider Organization (EPO)

  • This plan type allows you to see any doctor within a designated network without a referral. Out-of-network care is prohibited (barring an emergency).

Point of Service (POS)

  • A hybrid of PPO and HMO plan structures, the POS requires you to select a primary care physician but also allows out-of-network visits with a referral.

How Do I Choose My Provider Network?

Before you choose your health insurance plan, write down any doctors and specialists you’d like to have covered. For example:

  • any doctors you’re currently seeing
  • services you think you may need in the future

When you enroll, your health insurance company will ask you to choose from a list of providers. If you’re purchasing insurance directly through the Health Insurance Marketplace, you can search for different plans to see if your current doctors and hospitals are in-network.

FAQs

What if my current doctor isn’t in my new provider network?

If your policy is new and not yet active, you have until your policy’s effective date to change your plan. Once your coverage becomes active, you’ll need to wait until the next open enrollment period to make any changes.

There are exceptions. A Special Enrollment Period may be granted after certain life events. These may include:

  • Change in family size (marriage, divorce, the birth of a child)
  • Moving out of state
  • Certain changes in income
  • Receiving or losing employer-provided coverage

While accidentally choosing a plan without your preferred doctor isn’t a life event, an SPE would give you the chance to select a new provider network.

How do I find out which doctors are in my network?

Give your insurance company a call. They’ll be able to tell you which doctors you can see, and how much their services will cost you. Be sure you also understand what you’ll need to pay; many plans have different copayments and coinsurance for doctors and specialists–even if they’re both in-network.

Do Provider Networks ever change?

They do, but not in the middle of a policy; when contracts between provider groups and insurance companies are over, they renegotiate the terms of their agreement. This means your plan can change year-to-year, and it’s important not to assume that your coverage and list of in-network providers will be the same for the next year. Before you enroll, always verify that your plan’s provider network covers the doctors and services you need.

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