Your Provider Network: Why It Matters

There’s a lot to know as a consumer of health insurance. When you enroll in a health plan, it can feel like your vocabulary has been upended with words like deductible, out-of-pocket limit, coinsurance, and provider network.  

Your friends at Blue KC are here to help you understand the terminology and use it to get the most out of your health plan. Today we’ll unravel provider network, because once you know how to navigate it, you’ll save money and gain peace of mind.  

The Basics 

What is a provider network? Your Blue KC network is the group of providers and facilities you have access to for your healthcare. It includes primary care physicians, specialty physicians, hospitals, urgent care clinics, labs, x-ray providers, pharmacies, same-day surgery centers, and other healthcare professionals.  

What is an in-network provider? When a doctor or other healthcare provider joins a Blue KC network, they are considered in network and have signed a contract to charge lower rates negotiated by Blue KC. Once you’ve met your deductible, each time you visit an in-network provider, you will pay only a portion of those lower rates in the form of coinsurance or copayment. Blue KC will pay the rest. 

What is an out-of-network provider? A doctor who has not signed a contract agreeing to Blue KC’s lower, negotiated rates is an out-of-network provider. Depending on the terms of your health plan, out-of-network doctors may only be partially covered by your plan, or not at all.  

Four Reasons In-Network Matters 

Even though you may have access to out-of-network providers through your Blue KC plan,  you benefit by choosing in-network providers. Here’s why. 

1. Pay less for healthcare 

You’ll pay less for healthcare in two ways when you use in-network providers. 

• Lower rates – In-network providers typically agreed to charge lower rates than they would otherwise charge without insurance when they contracted with Blue KC. 

• Coinsurance/copayment – Once you meet your deductible, you’ll pay just a portion of providers’ charges in the form of coinsurance and/or copayment. 

Here’s how it works: Say your in-network doctor charges a negotiated rate of $200 for an office visit and your coinsurance is 10%. You’ll pay just $20 after you’ve met your deductible. And Blue KC will pay the remaining $180.¹ By contrast, visit an out-of-network doctor and their rate may be higher plus your out-of-network coinsurance will be higher. 

Why it matters? This is why you enrolled in health insurance – to pay less for healthcare. Depending on your plan’s stated coverage, coinsurance may be as low as 10% and copayment as low as $15 for a provider visit once you have met your deductible. 

2. Pay a lower deductible

Health plans that cover in-network and out-of-network providers generally have separate deductible amounts for each. For instance, your in-network deductible may be $1,500 while your out-of-network deductible may be $3,000.  

Why it matters? The sooner you meet your deductible, the sooner you only have to pay coinsurance or copayment for provider services. By seeing in-network providers, you’ll reach the lower in-network deductible far faster than the higher out-of-network deductible.  

3. Pay a lower out-of-pocket limit

Your plan’s out-of-pocket limit is the most you’ll pay for covered services in a year. Once you’ve spent the specified out-of-pocket limit, Blue KC pays your covered services for the remainder of the plan year. Health plans that cover in- and out-of-network providers generally have separate out-of-pocket limits for each. For example, an out-of-pocket limit may be $2,500 for in-network providers and $12,500 for out-of-network providers. 

Why it matters? When you meet your out-of-pocket limit, Blue KC pays your remaining covered services for the year. This is when you realize the full value of your health insurance investment. When you choose in-network providers, you’ll reach the lower in-network limit faster and enjoy the benefit of cost coverage. 

Learn more about lowering out-of-pocket medical costs by knowing where to go for care. 

4. Avoid balance billing

Balance billing is when an out-of-network provider bills you for the difference between their rate and what Blue KC will pay. Plus, you’ll also be responsible for the out-of-network coinsurance or copayment. When you choose in-network providers, balance billing is not even part of the conversation. 

Why it matters? You want to keep your healthcare bills as low as possible. Stay in network and avoid additional amounts such as those charged through balance billing.  

Find Providers in Your Network 

Staying in control of your healthcare spending starts with your provider network. If you haven’t already, check your network to make sure your existing providers are in network. you need to see a new doctor, make your network one of your first stops before scheduling an appointment.   

Blue KC makes finding providers in your network easy. Simply: 

• Visit your member portal at MyBlueKC.com
• Click Find Care in the left column 
• Click Find Doctors, Specialists & Hospitals 
• Use the search bar to find a specific doctor’s name, specialties, and procedures 

Have questions about your provider network? Contact your  Customer Service at the number on your member ID card. 

¹Based on hypothetical 10% coinsurance for in-network provider.