Navigating In-Network and Out-of-Network Charges

Whether you’re signing up for a health plan, searching for a doctor or just checking to see if you owe anything, the terms “in-network” and “out-of-network” are bound to pop up. And sooner than you might expect.

With open enrollment around the corner, keep this in mind: Know your network. It’s important because most of the time, there’s a difference in your costs between in-network and out-of-network. Over time, these costs can add up.

If you’re selecting a plan during open enrollment, network access is one of your most important considerations. If you’re using existing benefits, your choice of a particular doctor or hospital can make a big difference in the cost, and maybe even the quality of services you receive.

 

What to Look For

Let’s sort it out in a little more detail.

First, insurance companies contract with physicians, hospitals and other providers to purchase medical services at discounted rates for their customers. From there, insurers design specific health plans with different providers and different pricing levels. The providers under contract for that plan are considered “in network.”

There are many doctors and hospitals out there. And as part of our efforts to keep costs down, Blue Cross NC works closely with many North Carolina hospitals and physicians to help get you access to quality, affordable care, when you need it.

When you use an in-network provider, you’ll benefit by:

• Gaining access to our discounted rates that often result in lower costs for you
• Paying a lower deductible, meaning the amount you must pay before your insurance begins to pay [1]
• Paying lower out-of-pocket costs, meaning any medical payments other than the insurance premium you are responsible for and for which you won’t be reimbursed [2]
• Having preventive services that are covered at no cost to you [3]

Here’s an example: If you go to an in-network and have a $20 copayment, we pay the rest. The doctor’s actual charges might be, say, $150. But if you went to a doctor out of your plan’s network, your share of the cost will be much higher.

How could this affect you? When you’re shopping for a plan, it’s important that you know about the network. Check and see if any providers you regularly use are in the network for the plan you’re considering. Take a look at the complete network, as well, so that you understand what your options are in case you need additional providers in the future. Smaller networks generally come along with lower premium prices, assuming the benefits are the same, but you have to be comfortable with the trade-off of having fewer doctors in your network.

The Bottom Line

Whenever you’re facing surgery or any health issue, it’s always a good idea to check on the status of your provider before you receive care. And of course, if you’re facing a medical emergency, visit the nearest urgent care center or emergency department. It’s a good idea to get familiar with our guidance on whether to visit the ER or go to urgent care.

If you’re curious whether your doctor is in-network or not, you can use our ’find a doctor’ tool online. Blue Cross NC offers multiple types of products that are served by several different provider networks, so it’s important to be specific.

 

[1] If your plan has copays for certain services, you may not be required to meet your deductible first.

[2] This is true for NGF and ACA plans, but Grandfathered (GF) and Transitional (TR) plans still can have copays that aren’t required to be applied to the member’s Out of Pocket Limit.

[3] This does not apply to Grandfathered (GF) plans.

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