In Network, Out-Of-Network: What It Means, Why It Matters

Apr 24, 2014

When it comes to health insurance, "in-network" means a provider or facility that's contracted with your insurer to provide services at an agreed-upon rate. "Out-of-network" means a provider or facility that doesn't have an agreement with your insurer. Whether in-network or out-of-network providers and facilities are covered, and to what extent, depends on your particular health insurance plan.

Usually, in-network doctors and hospitals are cheaper for patients. The more in-network options you have, and the easier they are to get to, the better, right? Perhaps, as long as they're quality providers you can trust. A bigger network with tons of options isn't always better. It's having the right options for you that matters. And that's why the adequacy of a health plan's network matters.

Here's how a Robert Wood Johnson Foundation report explains it:

"Network adequacy refers to a health plan’s ability to deliver the benefits promised by providing reasonable access to a sufficient number of in-network primary care and specialty physicians, as well as all and other health care services included under the terms of the contract."

Rhode Island has spelled out some network adequacy standards (here's a link to the Department of Health's 2014 requirements). In a nutshell, they're about ensuring patients have access to an array of health care services where and when they need them. Of an insurer network's primary care practices, for instance, Rhode Island says at least 25% have to be open beyond the normal 9-to-5, to give people who can't get away from work or childcare during the day a chance to be seen by a doctor. And those providers have to be distributed throughout the state so that the plan's members have "reasonable" access to them.

The department will likely be holding up these standards to United Healthcare's request to drop Landmark Medical Center and 52 of its doctors from its plans. Can United, it may ask, cut those doctors and this hospital from its network and still maintain reasonable access for its members to the health care services they need, when they need them? United maintains in its request to the health department that it can, and that the changes aren't so drastic. It says it's encouraging the doctors it wants to drop to get admitting privileges at other hospitals so their patients can still see them elsewhere. Landmark says it wants a better deal from United, who it says hasn't raised its contract rates since 2010. The two are still in negotiations.

Bottom line, if you have United health insurance, live near Landmark, and have established a relationship with a doctor there, you'll want to pay attention to what happens. Your doctor may or may not remain "in-network." And that could impact what you pay for your health care or where you decide to get that care.