Network

A health insurance network is the group of doctors, hospitals, pharmacies, labs, and other providers that have contracted with a plan to provide care at negotiated rates. Providers in the network are called in-network. Providers not in the network are called out-of-network.

In-network care is much cheaper for you. Out-of-network care can be very expensive — or not covered at all.

Network types

Most Marketplace plans fall into one of these network types:

• HMO (Health Maintenance Organization) — You must use in-network providers. You usually need a referral from a primary care doctor to see a specialist. Out-of-network care is generally not covered except in emergencies.
• PPO (Preferred Provider Organization) — Broader network. You can see out-of-network providers, but at a higher cost. No referrals needed for specialists.
• EPO (Exclusive Provider Organization) — Must use in-network providers (like HMO), but no referrals needed for specialists (like PPO). Out-of-network care generally not covered except emergencies.
• POS (Point of Service) — Hybrid. You need a referral for specialists (like HMO) but can see out-of-network providers at higher cost (like PPO). Less common in Marketplace plans.

Most Marketplace plans these days are HMO or EPO, which keeps premiums lower at the cost of less flexibility.

Why network matters

Before enrolling in any plan, you should check:

1. Are your current doctors in network?
2. Are your hospitals in network?
3. Are your pharmacies in network?
4. Is the urgent care you would go to in network?

The fastest mistake people make on the Marketplace is enrolling in a cheap plan and then discovering their doctor is not in network. Switching plans mid-year is generally not possible without a qualifying life event.

How to check network status

• Use the plan’s online provider directory (often at the carrier’s website)
• Call the plan’s member services line
• Call your doctor’s office and ask which plans they accept
• Ask a licensed agent — they can pull network lists for every plan in your zip code

Network adequacy

The ACA requires Marketplace plans to maintain “adequate” networks — meaning sufficient providers within a reasonable distance for the populations they serve. State regulators enforce specific standards, which vary by state.

Emergency care

Federal law protects you from out-of-network surprise billing for emergency care at any hospital. Even if the ER is out-of-network, the No Surprises Act (effective 2022) prevents balance billing for emergency services. For non-emergency care, network rules still apply.

Narrow networks

Many Marketplace plans use narrow networks to keep premiums down — fewer providers and hospitals, but at lower cost. A plan from the same carrier on the Marketplace may have a very different (smaller) network than the same carrier’s employer plans.

Related terms

• Referral
• Prior Authorization
• Formulary
• Copay

Verify your doctors are in network — a licensed agent will check this for free before you enroll.