Understanding Networks

Your plan’s network is one of the primary factors that determine the total cost of ownership of your healthcare. You can save money by choosing providers within your plan’s network, so it’s a good idea to check if your preferred providers are in-network before choosing a health plan.

In-Network and Out-of-Network Coverage

Different plan types have different types of healthcare networks. Let’s look at some of the most common types and how they affect your available network of providers.

With a health maintenance organization, or HMO, you work closely with a primary care physician (PCP) that is part of a local network of providers. This PCP acts as the main point of contact for your healthcare needs, referring you to specialists within the plan network when needed. Out-of-network providers won’t be covered in the same way, and you could incur extra costs if you use them. So it’s a good idea to stay within the plan network except in the case of emergency.

With an exclusive provider organization, or EPO, you are also limited to a select network of providers. These types of plans do not cover care received outside the network except in an emergency. Unlike with an HMO plan, an EPO does not require a referral from a PCP to see a specialist, but again, it’s important to stay within the network unless you are prepared to pay out-of-pocket for care.

Finally, with a preferred provider organization, or PPO, it’s also recommended to stay within the large provider network outlined by the plan details. However, if you receive care outside this network, you may receive minimal coverage. This means that you will likely pay more than with care received within the network, but some portion of the visit may be covered. As with EPO plans, referrals are not generally required.

How to Check Which Providers are In-Network

Check your plan details ahead of time to see if your preferred providers are in-network. This will help save time when it comes to booking your healthcare appointments and save money on your out-of-pocket healthcare costs overall.

Remember that “providers” can include not just doctors, but other healthcare professionals like physical therapists, psychologists, hospitals and facilities. You can search the provider list by facility, area of specialty, provider name, and more. You can also call the plan’s customer service number for help finding these details. If you travel a lot, make sure the plan’s network has providers in places where you may seek care. 

Questions about Health Insurance Networks