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.

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 PPO plans.

  • In-network: You go to a doctor and the total charge is $250. You get a discount of $75 because you went to an in-network doctor and our negotiated rate with them is lower. We pay $140. You pay what’s left, which is $35.
  • Out-of-network: You go to a doctor and the total charge is $250. You won’t get a discount because the doctor is out-of-network. We still pay $140, but you’ll be responsible for what’s left, which is $110. We call this balance billing.

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.

Certain out-of-network services may be covered. Click the button below for examples of these services.

HMO and EPO plans

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

There are a couple exceptions:

  • If you have an accidental injury or medical emergency, we'll cover treatment no matter where you go.
  • If you can't get the treatment you need in your network, we might give you approval to go to an out-of-network doctor or facility. If you get our approval, we'll cover the treatment, but you may have to pay the remaining cost to the doctor or facility. We call this balance billing.

Get the most out of your health insurance plan. Make sure your doctor or hospital is in your network. 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 our networks in our Help Center.