In-Network versus Out-Of-Network Providers:

What’s the Best Option?

Choosing healthcare benefits is a big decision. You want to ensure you’re making the best choice for yourself and your family. You also want to select the most cost-effective plan. There can be a big difference between in-network and out-of-network service charges. However, by knowing the definition of in-network versus out-of-network providers, the available options, and protections set in place for the plan provider, you can make the right choice.
Here’s what you should know about choosing in-network versus out-of-network providers:

What does it mean to be in-network?

In short, in-network benefits are contracted, discounted rates you receive with certain health care providers. Insurance companies and health care providers form an agreement to specific terms. As a result, you will most likely pay less if you choose an in-network provider versus an out-of-network provider.

What does it mean to be out-of-network?

Out-of-network benefits include a non-discounted rate with providers not in the network with your insurance carrier. Some health care providers don’t form an agreement with the insurance company, so there are no limitations to what they can charge for services rendered. However, if you choose an out-of-network provider, your insurance carrier could pay a portion. This depends primarily on if your plan is an HMO or PPO.

What are HMO and PPO plans?

HMO plans will not cover out-of-network services. In other words, if a healthcare provider isn’t accepting of your insurance, you’ll be stuck with the entire bill under an HMO plan. PPO plans will however cover out-of-network services. If the healthcare provider is not under contract with your insurance carrier, a PPO will cover some of the cost. On the other hand, if there’s an emergency and you need immediate care, both insurance plans can help pay a portion of the services.

No Surprises Act will lessen “surprise billing”

Congress debated for months on the issue of insured Americans receiving “surprise bills” from out-of-network providers and medical professionals. For example, there’s little time to inquire if a provider is in-network or out-of-network in an emergency. Patients may receive care at an in-network facility. However, they may have obtained service from an out-of-network medical professional. The No Surprises Act resolves this. Beginning in 2022, this act proposes that patients won’t receive surprise balance billing. They will pay the deductible and copayment amounts as if using in-network benefits. Some states have already implemented laws to protect insured Americans. Federal law ensures more protection to those in states that haven’t established a protection law.

Choosing in-network versus out-of-network benefits can prove costly. Above all, to make the best decision for you and your family, know the difference, choices, and protections for in-network versus out-of-network benefits. Now you’re one step closer to being a plan participant expert!

For more guidance on in-network vs. out-of-network benefit plans, learn how Benefits Solutions Group can help.



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