The difference between in-network and out-of-network mostly relates to the contracts between providers and your insurance company. It’s what really makes a difference in your insurance coverage and out-of-pocket costs. In-network providers have contracted with your insurance company to provide services at pre-negotiated, lower rates than those outside the network. This means that when you are using someone in-network, more of the cost is covered by your insurance company, leaving less out-of-pocket for you. In addition, care in-network typically calls for lower co-pays and co-insurance rates; probably won’t require you to meet your deductible before coverage for some services is activated.
The latter, out-of-network care, means you get services from health professionals or healthcare facilities which do not have an agreement with your insurance company. Thus, these providers increase their rates, and your insurance company may pay less for the coverage—or in some cases, may not pay at all. It can result in far higher expenses out-of-pocket because you might be stuck paying the difference between what that provider charges and what your insurance is willing to pay. Sometimes, out-of-network care puts you in a position to meet higher deductibles before your insurance even starts covering the costs.
The choice of in-network versus out-of-network care may hugely impact the manner in which your insurance covers you. In-network care is typically lower in cost and has broader coverage, as most insurance plans are designed to provide maximal benefits through in-network providers. If you do or need to see someone out of your network, anticipate higher costs and likely more limited coverage. This makes a big difference, especially in times of emergency or when one needs specialized care, in that it affects what your pocket is going to be responsible for, including quality care. Before you seek care, it’s always good to check that the provider is in-network to avoid surprise bills.
