Free Assistance* from Licensed Agents
Marketplace America.org Health Insurance

Understanding In-Network vs Out-of-Network in Healthcare

in network vs out of network cost
Topics Covered

Meet Karen and Joe, members of the esteemed team at marketplaceamerica.org. Health insurance can be perplexing, but it’s an indispensable shield against unforeseen medical expenses. We’re here to simplify, educate, and guide you in making the best choices for your health.

Play Video about In-network vs out-of-network

Why Health Insurance Terminology Matters

Navigating the health insurance landscape requires an understanding of key terms. Without this knowledge, choosing the right plan for you and your family’s health needs can be challenging.

Key Health Insurance Terms

  • Premium: The monthly amount paid for your health insurance.
  • Co-Payments: A fixed fee amount you pay for a covered healthcare service.
  • Deductible: The amount you owe for health care services before your health plan begins to pay.
  • Coinsurance: Your share of the costs of a covered healthcare service.
  • MOOP (Maximum Out-of-Pocket): The maximum amount you’re required to pay in a year for covered services.
  • Health Plan’s Network: Healthcare providers your insurance plan has contracts with.
  • In-Network vs Out-of-Network Benefits: Crucial terms determining where you can get your care and how much you’ll pay.

In-Network Providers vs Out-of-Network Providers

  • In-Network: Refers to providers who have a contract with your health insurance plan. This often includes specific doctors or hospital systems.
  • Out-of-Network: Providers who don’t have a contract with your health insurance plan.
  • Being treated by out-of-network providers can become considerably more expensive. It’s vital to ensure your preferred doctors and hospitals are covered by your healht plan.
  • For instance, in-network costs might include a specific deductible, MOOP, and set prices for various services. In contrast, out-of-network might have higher or doubled deductibles and no MOOP limit.

Why Choose marketplaceamerica.org?

Marketplaceamerica.org aims to simplify health insurance. What differentiates them?

  1. Full Integration with healthcare.gov: Offering the same plans at the same prices.
  2. One-minute quotes and 10-minute enrollments: Quick and easy.
  3. Personalized Assistance: Licensed agents help at no extra cost.
  4. Hassle-free Experience: Prioritizing your privacy.
  5. Affordable Options: Some plans starting from $0/month.


Understanding the distinction between in-network and out-of-network health care providers is paramount in healthcare. Choosing the wrong participating providers can lead to exorbitant medical costs. It’s essential to be informed, understand the associated terms, and use trusted platforms like marketplaceamerica.org to ensure you and your family are adequately covered.

Remember: At Marketplace America, the aim is to provide more than just health insurance. They aim to give you peace of mind.

Click here to explore plans and prices on marketplaceamerica.org

Engage With Us:

Liked this explanation? Don’t forget to subscribe to our channel for more insights. If you have questions or topics for future videos, drop them in the comments. We’re here to help!


FAQ: In-Network vs Out-of-Network in Healthcare

What is the Difference Between in-network and Out-of-network?

The main difference between “in-network” and “out-of-network” pertains to the agreement between healthcare providers and insurance companies. In-network providers have negotiated a discounted in-network rate with the insurance company, making your costs lower. Conversely, out-of-network providers haven’t entered such an agreement, often resulting in higher costs for health care services.

What Does It Mean to Be Out of Network Coverage?

Being “out of network coverage” means that your chosen healthcare provider hasn’t entered a contractual agreement with your insurance company. While you can still receive care, the associated costs might be higher, and the insurance company might cover less or none of your medical expenses.

What's the Advantage of Going to an in-network Provider?

Opting for an in-network provider is financially advantageous. Since they have agreements with insurance companies, you benefit from discounted rates. This means lower out-of-pocket costs, better coverage, and often streamlined billing processes.

What Does It Mean if Someone is in Your Network?

If someone is “in your network,” it means that the health care provider or facility has a contractual relationship with your health insurance company. They offer services at reduced rates, which translates to lower costs for both you and the insurance company.

What is an Example of Out of Network?

An example of “out of network” provider is when you visit a specialist or a hospital that doesn’t have an agreement with your insurance company. In such cases, you might be responsible for a higher portion or even the entire bill, as the insurance might not cover or may only partially cover the costs.

Which is Better, HMO or PPO?

Whether an HMO (Health Maintenance Organization) or a PPO (Preferred Provider Organization) is better depends on individual needs. HMOs generally have lower premiums but require referrals to see specialists. PPOs offer more flexibility in choosing health care providers, both in-network and out-of-network, but may come with higher premiums.

In-network Vs Out-of-network Blue Cross Blue Shield - What's the Difference?

With Blue Cross Blue Shield, as with most health insurance companies, “in-network” providers have contracts that establish reduced rates for members. Conversely, “out-of-network” providers don’t have these contractual rates. Visiting an in-network provider under Blue Cross Blue Shield generally results in lower out-of-pocket expenses.

In-network Vs Out-of-network Cost - How Do They Differ?

Health Insurance network providers typically cost less due to the negotiated rates they’ve established with insurance companies. Out-of-network providers, without such agreements, often result in higher costs to the patient, with insurance covering less or not at all.

In-network Vs Out-of-network Deductible - What's the Distinction?

In-network deductibles are amounts you pay for covered services before the insurance starts paying. Since in-network services are generally cheaper, these deductibles can be lower. Out-of-network deductibles are often higher, as the services usually cost more without negotiated rates.

In-network Vs Out-of-network Dental - How Does This Work?

Just like with medical coverage, “in-network” dental providers have contractual agreements with dental insurance companies to offer services at reduced rates. On the other hand, “out-of-network” dental providers might charge higher rates, and insurance might cover less of the cost, if at all.

Need health insurance?

Call our Marketplace Call Center for free assistance* from licensed health agents.

Get a free health insurance quote today!

*Agents may be compensated based on enrollment in your health plan by the insurance company.