Network Definition | OnlineHealthIns.com Glossary

Network (In-Network / Out-of-Network)

Also known as: Provider Network, In-Network, Out-of-Network

The group of doctors, hospitals, and other providers that have agreed to accept a health plan's negotiated rates; using providers outside that group usually costs more.

A network is the set of doctors, specialists, hospitals, labs, and pharmacies that have contracted with your health plan to provide care at negotiated, pre-agreed rates. Providers in that group are considered "in-network." Anyone who hasn't signed such an agreement with your plan is "out-of-network."

In-network care generally costs you less because the plan and provider have agreed on set rates in advance.
Out-of-network care can cost significantly more, and some plan types, like HMOs and EPOs, may not cover it at all except in emergencies.
Out-of-network providers can sometimes bill you for the difference between their charge and what your plan paid, called balance billing.

Every plan type handles networks differently. HMOs and EPOs are usually strict about staying in-network, PPOs allow out-of-network care at a higher cost, and POS plans fall somewhere in between. Checking whether your preferred doctors and hospitals are in-network is one of the most important steps before enrolling in any plan.

People sometimes assume a hospital being in-network means every provider who treats them there is also in-network. That's not guaranteed. An in-network hospital can still have an out-of-network anesthesiologist or radiologist on a given visit, which is one reason surprise medical bills happen.

Example

A member confirms their primary care physician is in-network before enrolling, then later gets a bill from an out-of-network lab that processed tests ordered during an in-network visit.

Good to Know

Being treated at an in-network facility doesn't guarantee every individual provider involved in your care is also in-network.

Related Terms

HMO (Health Maintenance Organization) — A health plan that covers care mainly through a network of contracted providers and usually requires you to pick a primary care physician and get referrals to see specialists.

PPO (Preferred Provider Organization) — A health plan that gives you a network of preferred providers for the lowest cost, but still lets you see out-of-network providers and specialists without a referral.

EPO (Exclusive Provider Organization) — A health plan that only covers care from its network, like an HMO, but typically doesn't require referrals to see a specialist.

Out-of-Pocket Maximum — The most you'll have to pay in a plan year for covered services before your health insurance starts paying 100% of covered costs.