What Is a Network (In-Network vs. Out-of-Network)?

A network refers to the group of doctors, hospitals, and healthcare providers that have contracted with an insurance company to offer services at negotiated rates.

Defining “in-network” vs. “out-of-network” 

• In-network providers: Healthcare professionals and facilities that accept your insurance plan’s rates, resulting in lower costs for patients.
• Out-of-network providers: Providers who do not have a contract with your insurance, often leading to higher out-of-pocket costs or no coverage at all.

Why does your network matter?

• Cost savings: Staying in-network typically means lower copays, deductibles, and coinsurance.
• Coverage limitations: Some insurance plans, like HMOs, do not cover out-of-network care except in emergencies.
• Unexpected bills: Seeing an out-of-network provider may result in balance billing, where the provider charges you for the portion insurance won’t pay.

How does this apply to Medicare?

Medicare coverage works differently depending on whether you have Original Medicare or Medicare Advantage (Part C):

• Original Medicare (Part A & Part B): Does not have provider networks—you can see any doctor or hospital that accepts Medicare nationwide. However, some services, such as drug coverage through Part D, may have networks.
• Medicare Advantage (Part C): Operates more like private insurance, meaning you typically must use in-network providers for full coverage. Many Medicare Advantage plans are HMOs or PPOs, meaning out-of-network care may be limited or more expensive.

How Solace can help

A Solace advocate can help you find in-network providers, verify insurance coverage before an appointment, and avoid surprise medical bills. If you receive an out-of-network bill, an advocate can also assist in negotiating costs or appealing denied claims.

What to do next

Need help finding in-network providers or handling an out-of-network bill? Find an advocate today.