In-network vs. out-of-network
Why health insurance networks matter
Whether you’re signing up for a health plan, searching for a doctor or prescription, or just checking to see if you owe anything, the terms “in-network” and “out-of-network” are bound to pop up.
Networks can make a big difference in how much you spend on health care. When a provider, which includes doctors, hospitals, labs, and pharmacies, is considered in-network, they have a contract with your health insurance company to give you negotiated lower rates.
How costs work for in-network vs out-of-network
Let's say a doctor's fee for service is $200, but the doctor is in-network with your insurance plan and has a contracted rate of $120 for that same service.
You would only be responsible for $120. That saves you $80.
If you choose a doctor who is out-of-network and not a partner with your insurance plan, you'll be responsible for paying the entire amount of the doctor's bill.
Even with an insurance plan that covers some out-of-network costs, you may still have to pay more for covered services.
During an emergency, you should go to the nearest emergency room.
If you get emergency services from an out-of-network provider or facility, the most you can be billed is your plan’s in-network cost-sharing amount, such as copays and coinsurance. You can find what's covered under emergency room care in your benefit booklet.
Understanding surprise billing and unexpected costs
When thinking about the difference in costs between in-network and out-of-network care, it's important to know about surprise billing.
This is when certain provider groups practicing at in-network hospitals stay out-of-network. This tends to happen when doctors know patients have no choice but to see them for care. For example, an anesthesiologist during surgery.
Just because you are at an in-network hospital, that doesn’t mean the doctor seeing you will be in-network. To avoid surprise billing, check with the doctor and hospital about who will be giving you care and if they are in-network.
How to find in-network care
A directory of in-network doctors can typically be found on your insurance company's website.
Blue Cross and Blue Shield of North Carolina (Blue Cross NC) members can also use our Find Care search for in-network doctors and facilities.
Remember, doctors can change networks year to year, so it's best to also check in with your regular doctor during the annual Open Enrollment Period.
