Individual and Family
What Is an In-Network Provider? (Understand Your Health Insurance Plan)
Published on June 07, 2018
If your plan requires or prefers you to use in-network, providers, you probably want to know what this means in the first place.
A provider network is a list of health-care providers who are contracted by an insurance company, and provide medical care to those enrolled in plans offered by that insurance company. The providers in the health insurance plan’s network are called “network providers” or “in-network providers”. This term could apply to doctors, medical facilities, and other types of health-care providers.
Why do health insurance plans have provider networks?
Many health insurance plan types cut costs for their enrollees by having these networks full of in-network providers, according to America’s Health Insurance Plans (AHIP). These providers charge lower rates in exchange for being part of the provider network of a given insurance company.
Health insurance plans that have in-network providers are referred to as “managed-care” plans. This model has become increasingly popular, with the market now dominated by plans with a list of doctors and facilities for enrollees to choose from.
Three plan types that use in-network providers
Preferred Provider Organization (PPO): As the name suggests, these plans have preferred providers that have been selected for your use. While the insurance company does prefer you use their chosen, in-network providers, there is some flexibility with going out-of-network—it just may mean the insurance company covers less of the care rendered outside of the network.
Health Maintenance Organizations (HMO): With this type of plan, you will likely be more limited to the provider network of the HMO, and you will most likely need to choose a primary care physician (PCP) for all referrals. HMOs usually have lower premiums than other plan types, such as PPOs.
Point of Service (POS): Think of POS plans as a hybrid of HMO and PPO plans. You will likely have to choose a PCP within the health insurance plan’s network, but as with a PPO, you have the flexibility to go to out-of-network providers, perhaps just at a higher cost.
Choosing a plan is different for everyone. The amount in-network providers, and the flexibility to go out of network may be hugely important to some people buying a health insurance plan. Luckily, when shopping on eHealth you will get the information you need in order to make an informed decision about which managed-care plan you want to choose for your health insurance coverage. And if you decide that in-network providers and managed care aren’t for you, we have just as many resources when it comes to health insurance alternatives like medical indemnity insurance.
Keep in mind that each plan has its own terms and limitations, so be sure to check the official plan documents to understand how that specific plan works. This article is only for general education.
How do you know who is in your network?
eHealth has some convenient tools if you are shopping for a plan, and want to figure out who is in that plan’s network. This may be important to you if you already have a doctor in mind who you want as your primary care provider (PCP).
Use our Find a Doctor tool to get started on looking at plans that have certain doctors in-network.
Each insurance plan periodically updates its list of in-network doctors and providers, so always double check coverage with both the plan and the doctor or provider before incurring medical expenses.