All About: Healthcare Provider Networks
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 insurance 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. [i] 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.
