How are in-network and out-of-network health care providers different?

When it comes to health insurance, it can be confusing and frustrating to figure out what's what. All the fancy words and jargon don't make it any easier.

To help to clear the confusion, a good place to start is to understand the difference between in-network vs. out-of-network medical providers. Knowing the difference can help you save money on your medical bills.

What is a provider network?

A health insurance provider network is a list of physicians and care professionals, including hospitals and other care facilities (collectively known as providers), that have signed a contract with a health plan to provide services to members of the health plan at a discounted price. These providers are called in-network providers, or network providers for short. A provider that isn’t contracted with the health plan is an out-of-network provider.

Why do health insurance plans use provider networks?

Network providers typically offer medical care at a lower cost to the health plan and its members than to a person without insurance.

Why choose in-network providers?

Using in-network providers can save you money. Because these providers have agreed to offer services and treat conditions at a discounted price, they cannot charge the health plan more than the price agreed upon in the contract with the health plan. This cost-certainty helps the health plan manage costs, and in turn, members’ out-of-pocket costs are typically lower.

Going to out-of-network providers can be more expensive. If your health plan does not cover out-of-network benefits, you will be responsible for paying the full, non-discounted, price of care you receive from an out-of-network provider. Or, if the health plan does cover out-of-network benefits, your out-of-pocket costs could be higher than if you went to an in-network provider.

What happens in an emergency?

Health plans cover emergency care even if you’re in a situation where you may not have access to in-network services and your only option is out-of-network care. However, you may have to pay some out-of-pocket costs, like a deductible or copay, at in-network rates, depending on your employer’s plan type.

Why a big network matters.

A large, national network comes in handy if the unexpected occurs. If you’re on vacation and your child gets an ear infection or other illness, a health insurance plan with a big national network can help to ensure you’ll have in-network coverage wherever you may need care.

The Surest health plan uses the broad, national, UnitedHealthcare provider network. This robust network has 1.7M+ doctors and other health care providers and 7,000+ hospitals. The national reach of the UnitedHealthcare network means Surest members are likely to have access to in-network providers from coast to coast across the country.

How can members find out if a provider is in-network?

Health plan members can use a plan’s website or app as a resource to find information on whether a provider is in-network or not. They can typically search by the provider's name. Choosing an in-network provider can save a lot of money for the member, as outlined above.

Many people seeking health care start with a primary care doctor. It’s important to ensure this provider is in-network. If your primary care provider needs to refer you for additional health services, they typically consider your network and refer you to other in-network providers.

How the Surest health plan simplifies finding in-network care.

The Surest app or web version is designed to make it easy to find in-network providers. You can put the provider’s name into the search bar, or if you don’t have a particular provider in mind, you can search by provider specialty, such as dermatologist. You can also search by condition. For example, you can put “I have a headache” into the search bar to see provider options for your condition. If additional help is needed, Member Services representatives are available to assist, call the number on the back of your Surest member ID card.

The Surest app or website will display multiple provider options to choose from along with their prices. You can search, compare, and decide which option is right for you. And lower prices indicate providers evaluated as high-value options based on quality, efficiency, and overall effectiveness of care — providers who may help you feel better, faster.

When members choose lower cost providers, members and employers can save. On average, Surest reports a savings of 11% lower allowed per member, per month,1 and that members had 54% lower member out-of-pocket costs.2

Plus, with Surest, you don't have to worry about meeting a deductible before your coverage starts. It kicks in right away. The Surest health insurance plan has no deductible, and no coinsurance – your health plan helps pay for care from day one.

1Surest 2022 book of business plan sponsors with both medical and pharmacy data within our warehouse; industry 2022 commercial benchmarks and risk adjustment methodology. Risk adjusted for demographics, geography, and disease burden. 56_V04.

2Comparison of 2022 medical out-of-pocket spend for members who migrated to a Surest plan in 2022 compared to members from the same employers in a non-Surest plan. 141_V04.

You may also like...