What's the Difference Between In Network and Out Of Network?
When a doctor, hospital or other provider accepts your health insurance plan, at Blue Cross Blue Shield of Michigan, we say they’re in network. We also call them participating providers.
When you go to a doctor or provider who doesn’t take your insurance plan, we say they’re out of network.
The main differences between them are cost and whether your health plan helps pay for care you get from out-of-network providers.
When a provider joins our network, they agree to accept our allowable amount for their services. For example, a doctor may charge $150 for a service. Our allowable amount is $90. So as a member of Blue Cross Blue Shield of Michigan, you save $60.
You’ll see these savings listed as a discount on your claims and explanation of benefits statements.
Doctors or hospitals who aren’t in our network don’t accept our allowable amount. You’ll be responsible for paying the difference between the provider’s full charge and your health insurance plan’s allowable amount. That’s called balance billing.
If you have a medical emergency or you can’t wait for a doctor’s office to open, go to the nearest hospital or urgent care. In or out of network, all health insurance plans help pay for medically necessary emergency and urgent care services.
When it’s not an emergency, PPO and HMO plans work differently.
HMO plans don’t include out-of-network benefits. That means if you go to a provider for non-emergency care who doesn’t take your health plan, you pay higher out-of-pocket costs.
PPO plans include out-of-network benefits. They help pay for care you get from providers who don’t take your health plan. But you usually pay more of the cost. For example, your insurance plan may pay 80% and you pay 20% if you go to an in-network doctor. Out of network, your insurance plan may 60% and you pay 40%.