Important Insurance Terms – PPO, In-Network & Out-of-Network

• What is a Preferred Provider Network A PPO is a network of doctors and hospitals that are considered “In-Network” for your health insurance plan. You will usually pay less when you use an In-Network provider. Visiting an Out-of-Network doctor or facility often means higher out-of-pocket costs.

• What is an In-Network Provider?

An in-network provider is a doctor, hospital, or pharmacy that works with your health insurance company. They have a special agreement with the insurance company to give medical services at a lower price. This means if you go to an in-network provider, your insurance will cover more, and you will usually pay less money yourself.

• What is an Out-of-Pocket Maximum? An out-of-pocket maximum is a cap, or limit, on the amount of money you have to pay for covered health care services in a plan year. If you meet that limit, your health plan will pay 100% of all covered health care costs for the rest of the plan year. Some health insurance plans call this an out-of-pocket limit.

• Does it matter if I use an Out-of-Network Doctor or Hospital?When you go to a doctor or hospital that is out-of-network (not part of your insurance plan's list), it usually costs more. Here’s why:

  • Higher Costs: You might have to pay more for things like your doctor’s visit, tests, or treatment.

  • Less Coverage: Insurance companies have deals with in-network doctors for lower prices. If you go out-of-network, your insurance might not pay as much, and you’ll have to pay more.

  • Extra Bills: The doctor or hospital might ask you to pay the difference between what your insurance pays and what they charge. This is called "balance billing."

  • Out-of-Pocket Costs: There is usually a higher out-of-pocket annual cost for out-of-network care. So, you could end up paying more throughout the year.

In short, going out-of-network will cost you more money.

Questions about your PPO Network? Contact VISIT® Insurance at 703-660-9062 or info@visitinsurance.com and we will be happy to review your policy details with you.