In-Network and Out-of-Network Providers

Quick Facts and Information for Granite Staters

Glossary of Important Terms:

In-Network Provider: Most health insurance plans have a network of contracted facilities, doctors, and other medical providers who have agreed to provide services to their members at an agreed upon rate. The providers in the plan’s provider network are considered “in-network.” The important thing for you to remember is that you’ll usually pay lower out-of-pocket costs when you receive services from in-network entities.

Out-of-Network Provider: The facilities, doctors and other medical providers, pharmacies, and suppliers that do not have a contract with your health insurance plan to provide care to you are considered out-of-network. Out-of-network providers are typically not covered under a Health Maintenance Organization (HMO) plan. If you are covered under a Point of Service (POS) Plan or a Preferred Provider Organization (PPO) Plan, your services are usually covered, but may also be subject to higher cost sharing.

Health Management Organization (HMO) Plan: An HMO plan requires you to use In-Network Providers. You may be required to choose a physician, physician assistant, or nurse practitioner to serve as your primary care provider. Your primary care provider will coordinate your preventative care and manage additional care through referrals to specialists and other health care professionals.

Point of Service (POS) Plan: A POS plan is simply an HMO that permits limited access to Out-of-Network Providers for covered services, subject to higher cost sharing requirements.

Preferred Provider Organization (PPO) Plan: A PPO plan allows you to choose whether to use an In-Network or Out-of-Network Provider each time you receive care. Your cost sharing is lower when you use In-Network Providers. 

Know your rights:

Your health insurance company is required to ensure that your health plan includes:

  • Adequate access to services through the insurance company’s health care provider network for all your medical needs.
  • Access to health care services without unreasonable delay.

Your health insurance company is required to cover some of your out-of-network expenses in certain situations, including:

  • Emergency services.
  • Hospital services, such as lab work or anesthesiology services, when those services are delivered as part of the care you’re receiving at an in-network hospital.
  • Referrals. If your plan’s network doesn’t include a health care provider for the care you need, you may be able to obtain a referral so that the costs for those services are treated as in-network.

Common questions:

Can my insurance company deny me coverage from an Out-of-Network Provider?

Yes, your insurance company may deny coverage for non-emergency services or care that you receive at an Out-of-Network Provider. You should try to seek care at an in-network provider first. There are exceptions, however, listed in the section on the other side of this page (“Your Rights”).

I want to go to a particular doctor or facility. How do I know if the doctor or facility is In-Network or Out-of-Network?

Your health insurance company is required to provide you access to a provider directory that includes information on the In-Network Providers covered under your plan, and those who are accepting new patients. Visit your company’s website to access the provider directory for your plan or call the number on the back of your card for assistance. 

Who can help me?

Who can help me?

I have more questions.

To Compare Health Plan Costs, Visit The NH Healthcost Website.

This document is for informational purposes only. While the New Hampshire Insurance Department has made every effort to provide accurate information, some information has been generalized. Please contact your health insurance company to obtain specific information about your policy.

Contact Your Health Insurance Company

You’ll find their phone number on the back of your insurance card or visit their website.

Contact The NH Insurance Department Consumer Services Department.

While the New Hampshire Insurance Department has made every effort to provide accurate information, some information has been generalized. Please contact your health insurance company to obtain specific information about your policy.