When you need care, you want to know what you’re paying for with no surprises. Understanding how your health plan works, like the difference between “in-network” and “out-of-network” care, can help you feel more confident and avoid unexpected costs along the way.
What do “in-network” and “out-of-network” mean?
Health insurers work with a network of doctors, clinics, hospitals, and other care providers. These providers are considered “in-network,” meaning they have agreements with your health plan to offer care at lower, negotiated rates – making costs predictable for you.
Providers who don’t have an agreement with your health plan are considered “out-of-network.” They can cost more and may not be covered the same way as an in-network provider, or at all, depending on your plan.
Why should I stay in-network?
Getting care in-network is one of the easiest ways to make the most of your health coverage. When you stay in-network, you’ll usually have:
- Lower out-of-pocket costs
- More predictable coverage
- Better protection from unexpected bills
- Access to providers whose rates have already been negotiated with your health plan
To confirm whether your provider is in-network or out-of-network, contact your health plan directly. Quartz members can also:
- Log in to Quartz MyChart and use the “Find a Doctor” tool
- Search Find a Doctor using the network name printed on the back of your member ID card
- Contact Quartz Customer Success
What happens if I go somewhere or see a provider who is out-of-network?
Getting care from an out-of-network provider or facility may mean:
- Higher costs
- Different coverage rules
- Paying a larger share – or all – of the bill yourself
In some cases, your plan may not cover out-of-network care unless it’s approved in advance. This means getting prior authorization.
What is prior authorization?
Prior authorization is when your health plan has to review a requested service (whether an in-network or out-of-network service) ahead of time to determine whether it’s covered. Your doctor or care team will usually submit the request for you.
If approved and considered in-network, you can receive care and will be billed according to your in-network plan coverage.
If approved and considered out-of-network, you can still receive care, but it may come with higher out-of-pocket costs.
Learn more about prior authorization for Quartz members.
Do you have an HMO plan?
With an HMO plan, staying in-network is important. To get the most from your coverage, you’ll typically need to receive care from in-network providers.
Out-of-network care usually requires prior authorization and may not be approved if an in-network provider is available. If you have a medical emergency, you’re covered whether the emergency provider is in-network or out-of-network. Plus, if you’re on a Medicare plan, anywhere you get care must accept Medicare for it to be covered.
Additional resources
Click on the links below for more information related to important topics in this article.
- Where to get care – Learn when to choose primary care, urgent care, or emergency care
- Health plans 101 – Explore common health insurance terms and learn how health plans work
We’re here to help
Navigating health insurance is easier with support, and Quartz Customer Success is here to help with:
- Checking whether a provider is in-network
- Understanding coverage for a specific service
- Navigating next steps after a referral to a specialist
Call us at (800) 362-3310, Monday – Thursdays, 7 a.m. – 6 p.m., and Friday, 7 a.m. – 5 p.m.
*For Quartz Medicare Advantage (HMO) and Dual Eligible members: Out-of-network/non-contracted providers are under no obligation to treat plan members, except in emergency situations. Please call a Quartz Champion or review your Evidence of Coverage for more information, including cost-sharing details for out-of-network services.
