In-Network vs. Out-of-Network: What’s the Difference?

In regards to your insurance, you have probably heard the terms “in-network” and “out-of-network” care thrown around quite a bit by your provider. But what do these terms actually mean, and more importantly what do they mean for you?

Paperwork

Depending on the coverage you have purchased or that was set up by your employer, your plan has established deals with a wide range of doctors and dentists, as well as specialists, hospitals, etc. These are the health care providers that your insurance company considers in your “network.” This means that each of these health care providers is in agreement with your insurance company to accept your plan’s contracted rate as payment for their full services. This contracted rate that was negotiated by your insurance company includes both your insurer’s share of the cost, and the part that you will be responsible for paying. The part that you are responsible for paying may be in the form of a co-payment, co-insurance or deductible. For example, if your insurer’s contracted rate for a dentist visit might be $120. If you have a $20 co-payment for regular dental check ups, you will pay $20 when you see a dentist that is in your network. Your insurer will then be responsible for paying the remaining $100.

However, if you decide or are forced to go “out-of-network” for health care, you will most likely not have such a low co-pay. The cost of your care out of network will end up being a lot more of out-of-pocket costs to you. This is because any health care providers outside of your network
have not agreed to a contracted rate with your insurance company, and can therefore charge more for the care that they give you.
Depending on your plan, you may be required to cover higher co- pays or deductibles for out-of-network care. If you would normally have to pay 20% of the cost of the service for in-network dentists, you may be looking at paying 30% or more to see a dentist out- of-network. Be aware that it is also a possibility that your plan may not cover out-of-network care costs at all, and you would have to pay the full cost of care completely out-of-pocet.

It is important to understand the differences between in-network and out-of-network providers before choosing which dentist or doctor is right for you. Check with your insurance company to see which providers in your area are in your plan’s network.