In-Network vs Out-of-Network Hospitals Explained

Understanding the difference between in-network and out-of-network hospitals is essential for avoiding unexpected medical bills. Your network status can dramatically affect how much you pay for hospital care.

What Does "In-Network" Mean?

An in-network hospital has a contract with your health insurance company to provide services at pre-negotiated rates. This means:

• The hospital has agreed to accept your insurance plan's payment rates
• You pay lower out-of-pocket costs (copays, deductibles, coinsurance)
• Your insurance covers a larger percentage of the bill
• Bills count toward your plan's in-network deductible and out-of-pocket maximum

What Does "Out-of-Network" Mean?

An out-of-network hospital does not have a contract with your insurance company:

• The hospital can charge its full rates
• Your insurance may cover less or nothing at all, depending on your plan
• You may owe the difference between what insurance pays and what the hospital charges
• Costs may not count toward your in-network deductible or out-of-pocket maximum

The No Surprises Act

The federal No Surprises Act (effective January 2022) provides important protections:

• Emergency care: You cannot be billed at out-of-network rates for emergency services, even at out-of-network hospitals
• Non-emergency care at in-network hospitals: Out-of-network providers (like anesthesiologists or radiologists) working at in-network hospitals cannot send you surprise bills
• Air ambulance: Protections extend to air ambulance services from out-of-network providers
• Good faith estimates: Uninsured or self-pay patients can request upfront cost estimates

How to Check Network Status

• Call your insurance company's member services number (on your insurance card)
• Use your insurance company's online provider directory
• Call the hospital directly and provide your insurance information
• Ask your doctor which hospitals are in your network where they also have privileges
• Verify network status shortly before your procedure — networks can change

Important Tips

• Check everyone: Even if the hospital is in-network, some providers there (anesthesiologists, pathologists) may be out-of-network. The No Surprises Act protects against most of these surprise bills, but it's wise to ask
• Emergency exception: In a genuine emergency, go to the nearest hospital regardless of network status — emergency care protections apply
• Prior authorization: Some plans require pre-approval for hospital stays; failing to get it can reduce coverage
• PPO vs. HMO: PPO plans generally offer some out-of-network coverage (at higher cost); HMOs typically do not

Research hospital quality regardless of network status at Medicare Care Compare.

Data sourced from CMS and the Centers for Medicare & Medicaid Services. Visit Medicare Care Compare or call 1-800-MEDICARE.

Disclaimer: This article is for informational purposes only. Consult your insurance company for specific plan details.