What’s the difference between in network and out of network?

When a doctor, hospital or other provider accepts your health insurance plan 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 plan, we say they’re out of network.

The two main differences between them are cost and whether your plan helps pay for care you get from out-of-network providers.

In-network savings

When a provider joins our network, they agree to accept our approved amount for their services. For example, a doctor may charge $150 for a service. Our approved amount is $90. So as a Blue Cross member, you save $60.

On your claims and explanation of benefits statements, you’ll see these savings listed as a discount.

Doctors or hospitals who aren’t in our network don’t accept our approved amount. You’ll be responsible for paying the difference between the provider’s full charge and your plan’s approved amount. That’s called balance billing.

PPO versus HMO

When it’s 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 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 plan, you pay all costs.

PPO plans include out-of-network benefits. They help pay for care you get from providers who don’t take your plan. But you usually pay more of the cost. For example, your plan may pay 80 percent and you pay 20 percent if you go to an in-network doctor. Out of network, your plan may 60 percent and you pay 40 percent.

How to find in-network providers

When you use Find a Doctor on our website or mobile app, we only show you in-network providers.

Before you go to a doctor or hospital, it’s always a good idea to call and ask if they take your plan. Sometimes we aren’t notified right away when things change.


MI Asian
Author: MI Asian