Provider networks and referrals, explained

Plans with the same premium and deductible can feel very different in practice because of their networks. A network is the group of doctors, hospitals, pharmacies and other providers a plan has contracted with. Whether your providers are in it, and what the plan requires before you see a specialist, shapes what you pay and how easily you get care.

In-network and out-of-network

In-network providers have agreed to accept the plan's negotiated rates. When you use them, you generally pay your copayment, coinsurance or deductible and nothing more. Out-of-network providers have no such agreement. Depending on the plan, out-of-network care may be covered at a lower level, or not covered at all except in emergencies.

When you use an out-of-network provider, you may also face balance billing, where the provider bills you for the difference between their charge and what the plan paid. Federal law limits this in some situations, which is covered below.

Common plan types

Plans are often labelled by how their network works. The labels are a starting point, and the exact rules are in each plan's documents.

• HMO, or Health Maintenance Organization: typically covers care only from in-network providers, except in emergencies, and often asks you to choose a primary care doctor who provides referrals to specialists.
• PPO, or Preferred Provider Organization: typically lets you see in-network and out-of-network providers without a referral, with lower costs when you stay in network.
• EPO, or Exclusive Provider Organization: typically covers in-network care only, except in emergencies, but often without a referral requirement.
• POS, or Point of Service: typically combines features, with lower costs in network, referrals from a primary care doctor, and some coverage for out-of-network care.

How referrals work

A referral is approval from your primary care doctor to see a specialist. In plans that require them, seeing a specialist without a referral can mean the visit is not covered. Referrals usually need to be in place before the appointment, and some are limited to a number of visits or a period of time.

A referral is different from prior authorization. Prior authorization is approval from the plan itself, rather than your doctor, before certain services, procedures or drugs. A plan can require prior authorization even when it does not require referrals.

Protection from surprise bills

The federal No Surprises Act protects people in many plans from certain unexpected out-of-network bills. In general, it covers most emergency care, and some non-emergency care from out-of-network providers at in-network hospitals and facilities, such as an anaesthesiologist you did not choose. In those cases, you typically pay no more than your in-network cost sharing.

The protections have limits and conditions, and some states have their own rules as well. If you receive a bill you believe is covered by these protections, contact your plan and the provider, and keep copies of what you receive.

Checking a network before you enroll

Provider directories are the usual place to start, but they are not always current. Doctors join and leave networks, and an office may accept one plan from an insurer but not another. A careful check typically looks like this:

• Search the plan's provider directory for each doctor, hospital and pharmacy you use, using the exact plan name.
• Confirm with the provider's office that they participate in that specific plan for the coming year.
• Check which hospitals are in network, since that also affects which specialists you can easily see.
• If you travel or live part of the year elsewhere, check how the plan handles care outside its service area.

Networks often change at the start of each plan year. A doctor who was in network last year is worth checking again before you renew.

Choosing a network that fits

A narrower network often comes with a lower premium, which can be a sensible trade if your providers are in it. A broader network, or one with out-of-network coverage, can matter more if you see specialists, have ongoing treatment, or want flexibility. Weighing the network alongside the premium and deductible, rather than after them, tends to lead to fewer surprises during the year.

This guide is general education about how coverage typically works. It is not legal, tax, financial or medical advice. Plan rules, dates and availability vary by state and change each year.