What is a health insurance network?

In network vs. out of network explained.

A health plan network is made up of care providers that work with your health plan. This network affects how easy it is to get care and how much you pay for care.

Examples of the types of care providers in a network are:

• Primary care doctors and specialists
• Behavioral and mental health professionals
• Hospitals, clinics, and pharmacies
• Labs and imaging centers

These care providers agree to offer services at set rates. That helps lower your costs when you get care.

You’ll often see the terms “in network” and “out of network.” Knowing the difference can help you make better choices for your care and avoid higher costs. 

What is an in-network doctor? 

An in-network doctor or other care provider is part of your health plan’s network. These care providers have agreed to a discounted rate for covered services, so you'll pay less out of pocket when you visit them. Your costs may include a copay, a deductible, and your share of the costs (coinsurance). 

Why it helps to stay in network:

• Lower costs: You pay less for care because the rates are negotiated by your health plan. 
• No additional charges from the provider: Care providers in your plan’s network can’t bill you more than the rate they agreed to with your health plan.
• Simpler process: The care provider usually files claims for you. 

What is an out-of-network provider? 

An out-of-network doctor or other care provider is not part of your health plan’s network. They have not agreed to discounted rates. That means they can charge more for care. Your health plan may pay less — or not pay at all — for services you receive from them. 

Why you may want to avoid going out of network:

• Higher costs: Your health plan may pay only a small part of the costs or nothing at all.
• Additional charges from the provider: You may be billed for the difference between what your health plan pays and what the care provider charges. This is called balance billing.
• More work: You may have to pay upfront and submit a claim for reimbursement.  

Depending on your health plan, out-of-network costs may not count toward your deductible or out-of-pocket maximum.*

Is out-of-network coverage helpful to have?

Out-of-network coverage can give you more choice, but it often comes with higher costs or may not be covered depending on the plan. It may make sense if you:

• Have a long-term doctor or therapist who is out of network but you want to keep
• Need specialized care that’s not available in your plan’s network
• Live in an area with limited in-network options

What if my doctor refers me to another care provider?

If your doctor refers you to a specialist, lab, or imaging center, check that the care provider you were referred to is in your plan’s network. If they aren’t and you want to save on costs, you can ask your doctor for another option that's in network or contact your health plan for help. 

Can I use my health plan network when traveling?

If you need care while traveling, you may have coverage. Most Anthem Blue Cross and Blue Shield health plans include access to care across the United States. According to the Blue Cross Blue Shield Association, this nationwide coverage includes more than 2 million in-network doctors and hospitals . Still, not all doctors, hospitals, and pharmacies are in every plan’s network, so before you travel, it’s a good idea to review your plan’s coverage.^*

What if I need emergency care?

Emergency care is usually covered whether or not the provider is in your plan’s network. After you receive emergency care from an out-of-network hospital, check your plan details as soon as you can so you understand your costs and next steps. 

HMO and PPO: What’s the difference? 

Different types of health plans offer different types of coverage. When it comes to in-network and out-of-network care, health maintenance organization (HMO) plans typically only cover services from in-network care providers. If you use an out-of-network provider, you could be responsible for all of the costs for your care. HMOs also require you to select a primary care provider (PCP), a doctor who coordinates your care and refers you to specialists within your plan’s network.

Preferred provider organization (PPO) plans offer more flexibility. They usually don’t require you to choose a PCP or get a referral to see a specialist. They also allow you to see both in-network and out-of-network care providers — but your costs will be lower if you choose a provider in your plan’s network.

How do I find a doctor in my plan’s network?

You can find a healthcare provider in your plan’s network by using the Find Care  feature on our Sydney^® Health app or on our website. The tool lets you:

• Find doctors, hospitals, and virtual care 
• Search by location, specialty, or service
• Compare costs before you get care

Before your visit, always confirm the care provider is in your plan’s network. Even if a care provider accepts your health plan, they may not be in your specific network. Networks can change, so it’s a good idea to check each time you schedule an appointment. 

Understanding your health insurance network can help you lower your out-of-pocket costs, avoid unexpected bills, and find care more easily. The Anthem Blue Cross and Blue Shield network includes a wide range of doctors and hospitals, so you can feel confident choosing a plan that fits your needs and budget. 

* Some plans may have a combined or separate out-of-pocket maximum for out-of-network care, and you may be responsible for out-of-network costs in excess of your out-of-pocket maximum.
In certain situations, such as out-of-network emergency services, out-of-network cost sharing may count toward the yearly in-network out-of-pocket maximum. Please check your plan details for specifics.