Health Insurance 101 is a series aimed at addressing some of the most frequent questions we hear from members and businesses about their coverage.

Blue Cross and Blue Shield of Minnesota is dedicated to simplifying all areas of the health care experience. Part of our efforts include helping people understand their health plan and the key details that often can be overlooked or misunderstood.

In this edition of Health Insurance 101, we explore the concept of provider networks.

What is a provider network? And why does it matter?

A provider network is the defined group of doctors, clinics, hospitals and other health care providers that is associated with the benefits outlined in your health plan. A plan’s network serves as your access to care at the lowest cost, since Blue Cross has collaborated with the doctors, hospitals and clinics in your network to establish discounted prices.

What does it mean for a doctor or clinic to “participate” in a network?

A participating provider is any health care provider that has a payment agreement with Blue Cross. At Blue Cross and Blue Shield of Minnesota, 98% of doctors and 100% of hospitals in the state are under contract to participate in our network.

Every contracted (or participating) provider is automatically added to our largest network, called Aware. Often times this is referred to as the “Blue Cross” network. When a provider says that they accept Blue Cross, it means they have a current contract in place for your covered care.

In-network

The terms “participating” and “in-network” may sound the same, but there are major differences to keep in mind.

Participating providers can be included in different types of networks designed by Blue Cross – from our broadest Aware network to smaller, more customized networks, which often focus on location (different regions of the state) or are attached to specific insurance products.

One example is our “High-Value Network,” which constitutes a smaller subset of participating providers across Minnesota that meet specific cost and quality measures. Blue Cross sets these strict criteria to help ensure members with access to this network are receiving high quality care at an affordable price.

All of our networks are reviewed by state and federal regulators to ensure they meet specific access standards for every type of coverage, including employer-based benefits, individual plans, Medicaid and Medicare.

Out-of-network

If you receive care from a provider that accepts Blue Cross (has a contract in place), but is not included in your plan’s network, that is the definition of “out-of-network”.

The good news is billed charges from an out-of-network provider are based on contracted rates – so you still benefit from the discounted prices that were negotiated by Blue Cross.

What network status means for your bill

The not-so-good news is the amount you owe for any care received from an out-of-network provider is generally going to be higher than in-network care.

For example, if your health plan has a 20% coinsurance rate for in-network care and a 50% coinsurance rate for out-of-network care, costs can add up quickly by going outside your network.

The risks of seeing a “non-participating” provider

While “in-network” and “out-of-network” are key distinctions of providers under contract with Blue Cross, there is an entirely separate classification – the “non-participating” provider.

If a provider says they don’t “accept” Blue Cross, this means there is no agreement in place that regulates what they may charge to Blue Cross members. In other words, there are no contractual limits in place on what you can be billed. Additionally, any charges from a non-participating provider will not apply to your insurance plan benefits.

How do I know which providers are in-network?

Our Find a Doctor tool helps to identify in-network health care providers based on your specific health plan. This personalized experience is now integrated with our Care Cost Estimator tool, which means Blue Cross members who have insurance through their employer or the individual marketplace can also compare prices across all in-network providers.

The importance of knowing your network

Provider network access is an important consideration to make when selecting a health plan because it determines the group of health care providers you will have access to at the lower in-network rate. Blue Cross is a market leader in developing high-quality, cost-effective networks and our members benefit from having in-network access to a wide range of providers throughout the region at a competitive price.

For more information about your health plan’s specific network or how your benefits apply based on network status, check your health plan documents or contact customer service at the phone number on the back of your member ID card. Additional information on various types of provider networks based on your type of plan can be found here.