Posted May 08, 2025 by Anupreet Kaur, M.D., Medical Director, Care Management and Population Health
You’ve probably heard about “in-network” vs. “out-of-network” providers, but what exactly do these terms mean and why do they matter?
Consider this situation: You recently changed jobs and now have a new health insurance plan. However, after a recent visit to your primary care provider (PCP), you discover that your provider is now considered “out-of-network.” This means you’ll have to pay more out-of-pocket to continue seeing them or switch to a new PCP that’s “in-network.”
That’s why understanding provider networks matters. When shopping for health insurance, you’ll want to choose a plan with a provider network that includes the doctors and facilities you want and use most. It not only will save you money but a headache, too.
SummaCare answers your questions about provider networks and how they work, so you can better manage your care and get the most from your health plan — and hopefully avoid this common dilemma.
A provider network is a group of healthcare professionals and facilities that have contracted with a health insurance plan to provide quality care to members at a discounted rate. The providers within the group can include any person or entity that provides medical services to patients, such as primary care providers, specialists, hospitals, urgent care clinics, pharmacies, laboratories, medical equipment suppliers and other relevant entities.
These providers are often referred to as “preferred providers” or “in-network providers.”
A provider network is a group of doctors, hospitals and facilities that offer care at lower, negotiated rates through your insurance.
To avoid the dilemma mentioned above, it’s important to know the difference between “in-network” and “out-of-network” providers:
You’ll want to use an in-network provider because it can save you money in a few different ways. First, health insurers negotiate directly with the hospitals, facilities and providers for better prices which results in lower insurance premiums for members.
Another way provider networks save you money is by reducing your out-of-pocket costs when seeking care. Visiting an in-network provider usually means lower copays, deductibles and other costs for you. For out-of-network care, you may be required to pay the full price or a percentage of the services received.
Finally, when you seek care from an in-network provider, your out-of-pocket costs will be minimal, as in-network providers bill your insurance company directly. This means that you can seek care without being expected to pay a large bill upfront. Instead, the care provider will bill your insurance company first, making any necessary rate adjustments, and then bill you for the amount you owe after your claim has been processed.
It’s important to note that while a provider may be in-network, not all procedures they perform are automatically covered by your insurance. Some procedures might require prior authorization or may not be included in your plan’s benefits. For example, if your in-network provider recommends an in-office procedure, it’s a good idea to confirm coverage first—either by contacting your insurance plan or having your provider’s office verify it on your behalf. This extra step can help you avoid unexpected costs or misunderstandings.
Using in-network providers saves money—but confirm that specific procedures are covered to avoid surprise bills.
Yes. Some types of plans restrict your provider choices to in-network only, while others pay a greater share of costs for out-of-network providers.
There are many types of insurance plans designed to meet members’ different needs. Understanding the differences in plan options can help you better understand how to best minimize your out-of-pocket costs.
Here’s how provider network benefits vary depending on the type of health plan:
You can contact your health insurance company to find out which providers and facilities are in-network. You can also check the health plan’s online provider directory to see whether your provider or hospital is in network. Be sure to search the provider network for your specific plan, as insurance companies often have different networks for different plans.
In addition, many providers list the insurance plans they accept on their websites. It’s a good idea, though, to call the office to confirm — and ensure the list is up to date on their site.
Use your insurer’s directory and confirm with the provider’s office to make sure they’re in-network.
In addition to comparing premiums and out-of-pocket expenses on plans, it’s also important to review the details of their provider network details. Having access to an extensive network of hospitals, facilities, providers and suppliers is very important when considering a health insurance plan.
Begin by creating a list of healthcare providers and facilities you currently use. When comparing plans, search the directories to see if they’re in-network.
You’ll also want to check whether your plan covers out-of-network care and, if so, what the associated costs will be.
Lastly, consider any future healthcare needs. Maybe you were recently diagnosed with diabetes, or perhaps you’re planning to become pregnant. Make sure there are enough endocrinologists or, obstetricians and pediatricians in the network to meet your needs. You also may want to consider the distance to these providers and their availability.
A good provider network gives you access to the care you need—now and in the future.