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What’s the difference between in-network and out-of-network benefits?

Who is this for?

Michigan Health Insurance – Customer Service – Learn More

This information will help you if you're shopping for health insurance and have questions about how it works and how your money is spent.

In network or out of network? 

The answer to that question could affect how much you pay for your health care services.

If the doctor, hospital or health care facility you visit is part of your insurance company’s network, you'll get your health care at lower prices. But if you go out of your network for health care, it can become a lot more expensive.

If you have an HMO or EPO plan, you'll usually pay all costs for care you get outside of your plan's network. So it's important to carefully consider which doctors and hospitals are in a plan's network before you buy it.

PPO plans

Here's an example of how in-network and out-of-network benefits compare in a PPO plan.

You go to a doctor that's in network and the total charge is $250. A discount is applied to that amount for our negotiated rate with the doctor. The discount is $75. Blue Cross Blue Shield of Michigan pays $140. You'll have to pay the remainder, which is $35.

Now let's say you go to a doctor that's out of network. No discount is applied to the total charge. We still pay $140 but you'll be responsible for the remainder, which is $110.

Going out of network could mean you'll have to pay a larger percentage of the cost or the total cost, depending on your particular plan. You may also pay a higher coinsurance percentage and have higher annual coinsurance and out-of-pocket maximums.

Our PPO plans have the largest network of doctors and hospitals in Michigan. You can worry less because you'll find in-network doctors all around the state. 

HMO and EPO plans

HMO plans and EPO plans are different. These plans usually don't have any coverage for out-of-network care.

There are a couple of exceptions. If you have an accidental injury or medical emergency, we'll cover treatment no matter where you go. And if you need treatment that you can't get in your network, we might give you approval to go to an out-of-network doctor or facility. If you get the proper approval, we'll cover the treatment like we would if you went to an in-network provider.

To get the most out of your health insurance plan, it’s best to make sure your doctor or hospital is in your network. You can find out which doctors and hospitals are in each plan's network by looking at our individual and family plans.

You can also learn more about the Blues networks in our Help Center.

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