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All About: Healthcare Provider Networks

Smiling person with short hair wearing a light blue button-up shirt against a plain background.
Written by:
Aaron Garcia

Key Takeaways

  • Provider networks are groups of doctors and hospitals that work with private insurance companies to provide care within a specific geography.
  • Provider networks determine which doctors you can see and how much you pay for care. Your plan and carrier determine if your doctor is in-network or out-of-network.
  • Health insurance companies negotiate with doctors in their networks, which means you pay less for in-network services and more for out-of-network services.

Provider networks are groups of doctors, hospitals, facilities, and pharmacies that contract with private insurance plans. Your plan’s network may determine what doctors you can see and how much you pay for in-network care.

My Medicare coverage doesn’t address all of my needs.

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What Are Provider Networks?

Provider networks are groups of doctors, specialists, and hospitals that have negotiated contracts with a health insurance carrier. This network can help to coordinate the range of services included in your coverage.

Insurance companies categorize services provided by doctors and specialists as in-network and out-of-network. Your first choice should always be an in-network healthcare provider. You will receive more cost coverage for services received in-network rather than out-of-network. 

 

Does My Plan Have a Provider Network?

If you have health insurance through a private carrier, you likely have a provider network.

The details of your network depend on your health insurance plan type. Some plans, like HMOs, do not provide coverage for services deemed out-of-network.

Here is a list of plan types and how they use provider networks:

Health Maintenance Organization (HMO)

  • All providers must be in-network. Exceptions are typically granted only in emergencies.

Preferred Provider Organization (PPO)

  • PPO policyholders usually have a provider network but are allowed to visit out-of-network doctors and other specialists if they pay a higher price and file the claim themselves.

Exclusive Provider Organization (EPO)

  • This plan type allows you to see any doctor within a designated network without a referral. Out-of-network care is prohibited (barring an emergency).

Point of Service (POS)

  • A hybrid of PPO and HMO plan structures, the POS requires you to select a primary care physician but also allows out-of-network visits with a referral.

Your Ideal Medicare Plan is out there.

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How Do I Choose My Provider Network?

Before you choose your health insurance plan, write down any doctors and specialists you’d like to have covered. For example:

  • Any doctors you’re currently seeing
  • Services you think you may need in the future

When you enroll, your health insurance company will ask you to choose from a list of providers. If you’re purchasing insurance directly through the Health Insurance Marketplace, you can search for different plans to see if your current doctors and hospitals are in-network.

FAQs

If your policy is new and not yet active, you have until your policy’s effective date to change your plan. Once your coverage becomes active, you’ll need to wait until the next open enrollment period to make any changes.

There are exceptions. A Special Enrollment Period may be granted after certain life events. These may include:
  • Change in family size (marriage, divorce, the birth of a child)
  • Moving out of state
  • Certain changes in income
  • Receiving or losing employer-provided coverage
While accidentally choosing a plan without your preferred doctor isn’t a life event, an SPE would give you the chance to select a new provider network.
Give your insurance company a call. They’ll be able to tell you which doctors you can see, and how much their services will cost you. Be sure you also understand what you’ll need to pay; many plans have different copayments and coinsurance for doctors and specialists–even if they’re both in-network.
They do, but not in the middle of a policy; when contracts between provider groups and insurance companies are over, they renegotiate the terms of their agreement. This means your plan can change year-to-year, and it’s important not to assume that your coverage and list of in-network providers will be the same for the next year. Before you enroll, always verify that your plan’s provider network covers the doctors and services you need.

Sources

This website is operated by GoHealth, LLC., a licensed health insurance company. The website and its contents are for informational and educational purposes; helping people understand Medicare in a simple way. The purpose of this website is the solicitation of insurance. Contact will be made by a licensed insurance agent/producer or insurance company. Medicare Supplement insurance plans are not connected with or endorsed by the U.S. government or the federal Medicare program. Our mission is to help every American get better health insurance and save money.

Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.