In-Network vs. Out-of-Network Providers

What is an in-network provider?

To help you save money on health care costs, most health plans provide access to a network of doctors, facilities, and pharmacies. The doctors and facilities in the plan's network must meet certain credentialing requirements and agree to accept a discounted rate for covered services under the health plan in order to be part of the network. These health care providers are considered in-network.

What is an out-of-network provider? 

If a doctor or facility has no contract with your health plan's network, they're considered out-of-network and can charge you full price. The cost of services is usually much higher than the in-network discounted rate.

Not all plans cover out-of-network services, so it’s important to understand your plan benefits before you seek out-of-network care.

Why does out-of-network care cost more?

• You're probably paying full price. When health insurers don't have a contracted relationship with out-of-network doctors and facilities, they can't control what is charged for services. And rates may be higher than the discounted in-network rate.
• Your share of the costs is different (and usually higher). When you choose to use an out-of-network doctor or facility for covered out-of-network services, your cost-share is usually much higher than the in-network cost-share. Cost share can include a deductible, copay, and/or coinsurance.
• You may have to pay the difference. If the doctor or facility's bill is higher than what your plan will pay, you might have to pay the difference. Many health plans list the amount that is the most they'll pay for out-of-network services. If the doctor or facility charges more than your plan's maximum, you could be responsible for paying the difference in addition to your deductible, copay, and/or coinsurance. In-network doctors and facilities have agreed not to charge you more than the agreed-upon cost.

Learn more about costs: copays, deductibles, and coinsurance

In-Network Vs. Out-of-Network Costs

You can avoid unexpected medical bills by understanding how your plan works. Choosing out-of-network providers can affect what you'll pay out of pocket. Know the difference between in-network and out-of-network care to help save on health care expenses.

Out-of-network costs can add up quickly, even for routine care. If you have a serious illness or injury, it can mean paying thousands of dollars more. Here's an example of doctor charges for a surgery¹:

Provider Network Frequently Asked Questions (FAQs)

What is a provider network?

When you choose a plan, you will typically have access to a specific health care provider network. Some networks may be larger than others or may include different choices of health care providers in your local area. It's important to understand these differences when choosing a plan to meet your specific needs. Also, when you choose a plan, make sure your health care provider is part of the network associated with that plan.

How do I check if a provider is in-network?

If you have a Cigna Healthcare^® plan or are considering enrolling in a Cigna Healthcare plan, find out which network is included and then search our provider directory.

Why might  I choose an out-of-network provider?

Sometimes you may wish or need to go to a provider who's out of network, even though it costs more. This may be because they have specific skills or experience with a certain condition. They may also be located closer to you. You may also choose to continue seeing a provider who is no longer in network because you already have a relationship with them.

Do I need to see a doctor within my plan's network for my expenses to be covered?

Plans may vary, but in general to save on out-of-pocket costs, you should visit in-network providers. If your plan includes out-of-network benefits, eligible expenses are covered but your out-of-pocket costs may be higher. Depending on the plan you choose and where you live, network availability may vary. Refer to your plan documents for network details. When you've decided which plan you'd like, you can visit the provider directory to see if your providers are in-network for your plan.

Do I need to select a primary care provider (PCP) before my coverage begins?

If you are purchasing Individual and Family Plan coverage through a state or federal health insurance marketplace, a PCP may be assigned to you. You may change your PCP after your planned start date.

If you are enrolling in a health plan through your employer, review your employer's plan details to see if you're required to choose a PCP or if choosing a PCP is optional. You can also check if there are any network requirements for your plan.

Do I need a referral to see a specialist?

Depending on your plan, a referral from your PCP may be required to see a specialist, such as a gastroenterologist or cardiologist. Under all plans, referrals are not required for OB/GYNs for covered obstetrical or gynecological services. See your plan documents for details.

Am I covered outside of the service area and outside of the country?

Depending on your plan, benefits may or may not include out-of-network coverage. Refer to your plan documents for important coverage information. Outside of the United States, coverage is limited to emergency services as defined in the plan documents.

If you receive coverage through your employer, your employer may offer coverage for health care services received outside of the country when you are travelling for work purposes. Contact your employer for details.

Can I go to any health care provider if I'm traveling?

Depending on your plan, benefits may or may not include access to in-network and out-of-network benefits while traveling. Coverage and reimbursement varies by plan. Refer to your plan documents for details.

Reference the provider directory to find health care providers in your plan's network. Emergency services are always covered².

¹ This is an example used for illustrative purposes only. Actual covered charges and out-of-pocket costs will vary by plan. Refer to your plan documents or call the number on your ID card for details about your specific medical plan.

² Emergency services as defined in the plan documents. Eligible out-of-network emergency services are covered at the in-network benefit level as defined in plan documents.