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In-network vs. out-of-network care: How to know the difference
Understanding how your health plan works can help you manage your health care expenses. For example, some health plans cover services from providers that are out of your network. You may have higher costs if you get care from those providers. Other health plans only cover services from providers in your network. Kaiser Permanente’s network works differently than most other health plans. Learn more about our network at the end of this article.
You may be able to avoid unexpected bills by knowing if your doctor or medical facility is in network or out of network. Here’s how to tell the difference and how to find doctors in your network.
What is in network vs. out of network?
Health plans have a group of contracted doctors and facilities that they negotiated their rates with — this is their network. If your health plan covers services from providers that aren’t in the network, you may have to pay more to see those providers. Getting care from a network provider can save you money. That’s why it’s important to understand the difference between in-network vs. out-of-network care.
In-network care
A doctor, health care professional, or facility that’s in network has a contract with your plan. Your plan decides to pay a specific amount for a service, and the provider agrees to accept that rate. Depending on your coverage, you might pay none or part of that cost yourself, plus your copay, coinsurance, or deductible. These are your out-of-pocket costs.
Out-of-network care
An out-of-network doctor or facility doesn’t have a contract with your plan. Getting care out of network could cost you more than in network because the rate isn’t negotiated beforehand. The provider decides how much to charge for a service, and your plan may not cover the entire cost. You’ll likely pay the difference, as well as your out-of-pocket costs — your coinsurance or deductible. (Out-of-network care doesn’t usually include a copay.)
Most plans don’t cover any care outside of their network unless it’s for an emergency.1 In that case, you could be responsible for the entire cost of any out-of-network care you get. To be safe, confirm your care will be covered before you go.
When to check if care is in network or out of network
There are many times when you might confirm whether a doctor or location is in your network. For example:
- You change plans and need to find a new primary care doctor.
- Your primary care doctor recommends you see a specialist.
- You move to a different town and want a new doctor closer to home.
- You want to see a mental health or substance use disorder professional.
- Your doctor orders a lab test, X-ray, or treatment that’s not available at their office.
- You need to visit an urgent care and you’re not sure where to go.
When you have an emergency, you don’t need to worry about your care being out of network. Health plans consider emergency care to be in network.
What type of care can I get?
Whether you can choose between an in-network or out-of-network doctor depends on what type of plan you have. The most common types are known as HMOs and PPOs.
- Health maintenance organization (HMO) plans — Only in-network care is covered. Your primary care doctor will refer you to most specialty care. HMO plans often have lower monthly costs.
- Preferred provider organization (PPO) plans — Both in-network and out-of-network care are covered, but at different rates. You can see a specialist without a referral. PPO plans offer more choice and flexibility, usually at a higher monthly cost.
- Other mixed-network plans — Depending on the provider, there are a range of plans that combine in-network and out-of-network coverage. Some plans will cover out-of-network care for a certain number of visits each year, or if you have a referral from your primary care doctor.
If you have a plan that covers out-of-network care, there are a few reasons you might choose to get care that way, even if the out-of-pocket costs are higher. For example:
- You need to get care in an area where no in-network options are available.
- Your doctor has left your network, but you still want to see them.
- You need to see a type of specialist that isn’t available in your network.
How do I find doctors in my network?
There are a few ways to make sure a doctor or facility is in your plan’s network.
Your plan likely has an online directory where you can search for doctors, specialists, hospitals, pharmacies, labs, and other clinicians that are in your network. If you need help, call the number on your ID card.
You can also contact the doctor’s office or facility and confirm whether they’re in your plan’s network.
Remember, even if a doctor or facility is in network, you may need a referral from your primary care doctor. Check with your doctor or call your plan if you’re not sure.
The Kaiser Permanente network
When you’re a member, care from Kaiser Permanente doctors and facilities is always in network. These providers contract exclusively with Kaiser Permanente. You can also get in-network care from certain clinicians, hospitals, and pharmacies that have contracts to provide care for Kaiser Permanente members.
If you need specialty care, your primary care doctor can connect you with the right physician. They’ll work together to coordinate your treatment, so you get seamless care that you know is covered.
If you enroll in a Kaiser Permanente plan that provides coverage for services from providers that aren’t in the network, you still have access to the Kaiser Permanente network.
Footnote
1If you believe you have an emergency medical condition, call 911 or go to the nearest hospital. For the complete definition of an emergency medical condition, please refer to your Evidence of Coverage or other coverage documents.