Understanding Your Health Plan’s NetworkMay 06, 2021
Your health plan’s network of healthcare professionals and facilities makes it convenient for you to find affordable, high-quality care quickly, whether you’re needing preventive care or experiencing health issues.
Your health plan network includes doctors, specialists, hospitals, pharmacies, labs, and urgent care centers that are contracted by your health plan to provide you with care at lower rates. Providers in your plan are called in-network, participating, or preferred providers. Anthem reviews doctors and facilities in your network to ensure they meet high standards of care. These contracted providers file your claims for you and help you request preapprovals, if needed.
Healthcare professionals and facilities who are not contracted with your health plan are considered out-of-network providers. They can charge you any amount, which is generally higher than what in-network providers charge. Your plan pays the allowed amount for the service, and the provider bills you for your usual share of the cost, plus the balance. This is called balance billing. Since the provider is out of network, you typically have to file your own claims and request preapprovals, if needed.
Understanding your health plan and network
Certain health plans, such as health maintenance organizations (HMOs), cover services from in-network providers only. You could be responsible for all of the charges if you use an out-of-network provider. HMOs also require you to select a primary care physician (PCP), a doctor who coordinates your care and refers you to specialists within your network.
Preferred provider organizations (PPOs) are health plans that don’t require you to choose a PCP — but your costs will usually be lower if you select in-network doctors.
Save money by using providers in your plan
Suppose you visit a doctor who charges a total fee of $250. Here’s how your costs may break down:
- If the doctor is in-network, you and your health plan would pay your portions of your doctor's negotiated rate. For example, if that rate was $175, and your copay was $35, you'd pay $35 and your plan would pay $140.
- If the doctor is out-of-network, your plan would still pay the same $140. You would be responsible for your $35 copay, plus the remaining balance of $75 because the doctor has not agreed to a discounted rate. You’d end up paying $110 instead of just $35. If you have an HMO, you would have to pay the total fee of $250 because the plan only covers in-network providers.
How to find doctors in your network
You can use our Find Care tool online or the Sydney Health mobile app. The tool allows you to customize your search for certain specialties, medical services, and locations. You can also find vision, dental, and behavioral health professionals.
When you make an appointment, always confirm that the doctor or facility is in-network. Doctors who say they "accept" your coverage aren't necessarily in your plan network, and you could end up paying more than you should.
Your Anthem plan comes with a strong network that offers high-quality care and cost savings. It’s an important part of our commitment to help simplify your experience and give you more confidence in making healthcare decisions.