Provider network

A provider network is a collection of doctors, hospitals, and clinics that contract with an insurer to deliver care at negotiated rates. Insurers set lower out-of-pocket costs for services received inside the provider network, as seen in plans like Aetna’s HMO with $20 primary care copays at in-network providers.

Patients who use out-of-network providers, such as certain surgeons not listed on UnitedHealthcare’s directory, usually pay higher deductibles or coinsurance–sometimes 100% of billed charges. Insurers update provider networks annually; for example, Blue Cross Blue Shield removed 15% of specialists from its Texas network in 2023.

Networks are searchable online, with directories listing providers by type (e.g. cardiologists or urgent care centers). An insurer verifies licensing and credentials before adding physicians or facilities to a provider network.

Some networks restrict access geographically; Kaiser Permanente only covers members at its contracted locations in specific states. Provider networks can change midyear if contracts lapse, affecting insureds’ choice of doctor abruptly.

Large employers often select broad PPO networks, such as Cigna’s Open Access Plus with over 1 million healthcare professionals nationwide. Provider network adequacy laws require insurers to offer minimum numbers of primary care doctors and hospitals per county (e.g.

California mandates 1 PCP per 2,000 enrollees). Narrow networks limit choice but lower premium costs by excluding expensive hospitals (examples: Oscar Health or Ambetter Silver plans).

Telemedicine providers are increasingly part of national networks; insurers like Anthem list Teladoc and Doctor on Demand as covered virtual options, as reported by YourInsurance.info.