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An AmeriHealth Explainer About In-Network and Out-of-Network Providers

By December 19, 2023January 17th, 2024Featured Health Insurance Member Resources
A father and son with the pediatrician in her office.

When you’re choosing a doctor or other health care provider, there are lots of factors to consider. How close or convenient are they to your home? Are they accepting new patients? Are their online reviews mostly positive? Were they recommended to you by someone you know?

Another consideration is whether they’re in-network for your health insurance plan. All health plans have a network of health care providers who’ve signed a contract with them. Selecting a provider who is in that network can save you money. In fact, some plan types require you to see an in-network provider.

The questions and answers below should help you understand the difference between in-network and out-of-network providers and how to know which ones are in your plan’s network.

What is a provider?

A health care provider is a person or company that delivers a health care service to you. This includes your primary care physician (PCP), specialists, and even facilities, like labs, hospitals, and urgent care centers.

What does in-network mean?

In-network refers to a health care provider that has a contract with your health insurance plan to provide health care services to its plan members at a pre-negotiated rate. Because of this relationship, you pay a lower cost-share when you receive services from an in-network doctor.

What does out-of-network mean?

Out-of-network refers to a health care provider who does not have a contract with your health insurance plan. If you use an out-of-network provider, health care services could cost more since the provider doesn’t have a pre-negotiated rate with your health plan. Or, depending on your health plan, the provider’s services may not be covered at all.

How do I know if a doctor is covered by my insurance?

If you’re an AmeriHealth member, use our Find a Doctor tool, which makes it easy to find in-network health care providers! Enter your location and health plan, and your search will return results for providers who are in your network.

Is it more expensive to see a provider outside of my health plan’s network?

Yes, typically you’ll pay more if you go to an out-of-network provider. Keep in mind that some health plans don’t have any coverage for non-emergency services received from an out-of-network provider; see HMOs, EPOs, and PPOs below. Be sure to check your benefits before picking a provider.

HMOs, EPOs, and PPOs

A chart showing the difference between HMO, EPO, and PPO plans
  • Here’s how the most common types of health plans work:
    • HMOs, or health maintenance organizations, require you to choose a PCP who is in their network, and won’t cover services from a specialist unless you get a referral from your PCP. HMOs typically have the lowest premiums.
    • EPOs, or exclusive provider organizations, don’t require you to get a referral to see a specialist, but they still only cover services from in-network providers. Their premiums are usually somewhere between those of HMOs and PPOs.
    • PPOs, or preferred provider organizations, don’t make you choose a PCP, don’t require specialist referrals, and will cover services from out-of-network providers. And you still save money by using providers that are in-network. PPOs typically have the highest premiums.

    What are the benefits of choosing providers in the AmeriHealth network?

    AmeriHealth has one of the largest networks of doctors and hospitals in our state. In addition to paying lower out-of-pocket costs, you also have the security of knowing that we’ve screened the providers in our network to ensure that they meet our quality standards.

    Learn more

AmeriHealth Team

The AmeriHealth Team is here to provide well-being tips and health insurance education to help you be your healthiest.