In-Network Vs. Out-of-Network Insurance Benefits

When you are exploring the different options for your health insurance, and are zeroing in on a plan, you might have stumbled upon the terms “in-network” and “out-of-network.” Have you ever wondered what they are?  Should you care about these terms? If your agenda is to save money and not pay more, you should pay full attention to these important health care terms.

When are You In-Network?

Your insurance company has a contract with certain providers. These providers can be doctors, specialists, labs, facilities, pharmacies, etc.  Your insurance company sets pre-negotiated rates with these providers for their services. Thus, you, your insurance company, and these providers are “in-network.” When you operate “in-network” your part is to pay the deductibles, or co-pay, or co-share, and the rest is covered by your insurance company based on a pre-negotiated price with the provider. The advantages may be:

  • Discounted rate for the service
  • A hassle-free experience: You walk to the hospital or doctor’s office, pay a small amount (your deductible/co-pay), obtain the required service, sit in the car, and drive away.

When are You “Out-of-Network?”

When you go outside the list of providers identified by your insurance company, you go “out-of-network.” There are no pre-negotiated rates or contracts between your insurance company and the providers.

The disadvantages may be:

  • No discount  available
  • Because of lack of understanding and communication between your insurance company and the provider, you might pay a major chunk of the out of network expenses.

Why would You Go Out-Of-Network?

Life may not turn out exactly as we expect.  Emergencies might arise and going “out-of-network” will be inevitable. Or your personal care physician may refer you to a specialist or facility that is “out-of-network.” Don’t assume anything and perhaps you may prevent going “out-of-network.” You can make inquiries and check with your insurance company or the provider before you schedule an appointment or receive services.  Browse through your insurance company’s website thoroughly, read the plan booklets, or call your insurance company to know the limits of your coverage.

Ultimately, be an informed denizen, and take control of your healthcare benefits, coverage, and costs in your hand.

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