Network

Health insurance plans usually have a network of health care providers, with whom they negotiate prices for certain services. These doctors, hospitals, and other providers may be called “in network,” “preferred,” or “participating.” If a plan enrollee uses a provider that is in the plan network, the plan will pay some or all of the costs of the care delivered by the provider depending on whether the enrollee has met his deductible and the type of service. Health insurance plans may also provide some coverage for services received “out of network” but may require enrollees to pay a higher share of the costs for these services. For example, a higher deductible, copayments and/or coinsurance may apply to out-of-network care than for care provided by the plan’s network of providers. In addition, the full charge (or total cost) of the service may be higher, because the out-of-network provider can charge more than the amount the plan has negotiated with providers in the network. For example, if an enrollee sees a physician who is outside of her insurance plan’s network, and the physician charges $150 for the visit, but the plan’s allowed amount (discussed below) is $125, then the insurer will pay only $125 minus any cost-sharing charges that apply. In addition to the cost-sharing charges, the enrollee would be responsible for the $25 difference between the allowed amount and the full amount charged for the service.