Health insurance networks are the doctors, hospitals and labs a plan has contracted with. In general, a smaller network means a lower premium, while a broader one costs more each month. However, the cheapest plan only saves money if your doctors are in it. Otherwise, out-of-network bills can wipe out what you saved on premiums.
- One study of Marketplace silver plans found plans with narrow doctor and hospital networks cost about 16% less than plans with broad networks.
- HMO and EPO plans generally don't cover out-of-network care except in an emergency.
- Out-of-network care doesn't count toward your yearly out-of-pocket limit, which is $12,000 for one person in network for 2027 coverage.
- The No Surprises Act protects you from many surprise out-of-network bills for emergency care.
- Total yearly cost, meaning premiums plus the care you use, is the number to compare.
What are health insurance networks?
A network is the group of providers that agree to a carrier's prices. In exchange, the carrier sends its members to them. Every carrier builds its own provider networks, and they can differ from plan to plan. So when you see an in-network doctor, you pay your share of a discounted price.
Outside the network, things change fast. The carrier may pay less, or nothing at all. Also, the provider can bill you the difference between their charge and what the plan pays. That's called balance billing. Our guide to in-network and out-of-network costs explains it step by step.
How network size changes health insurance costs
Carriers can charge less when they work with fewer providers. That's because a smaller network can bargain for lower prices in exchange for more patients. As a result, health insurance networks with fewer doctors and hospitals usually come with lower premiums.
Research backs this up. A Health Affairs study looked at Marketplace silver plans in 2014 and 2015 across eight states. Plans with narrow doctor and hospital networks cost about 16% less than plans with broad networks for both. Even narrowing just one of the two cut premiums by about 6% to 9%.
The meter shows relative premiums from that study, with a broad plan set at 100. Your own prices will differ by state, carrier and age. Still, the general pattern is the same: fewer providers, lower price. To see the other things that move your price, read what drives your monthly premium.
Network types from narrowest to broadest
Plan type tells you how strict the network is. Here's how HealthCare.gov describes each one.
| Plan type | Out-of-network care | Typical trade-off |
|---|---|---|
| HMO | Generally not covered except emergencies | Lower premium, but you stay in network |
| EPO | Covered only in network, except emergencies | Similar to an HMO, so check your doctors first |
| POS | Usually covered at a higher cost | So you need a referral to see a specialist |
| PPO | Covered without a referral, for an added cost | More freedom, plus a higher premium |
For a deeper look, compare how HMO and PPO plans differ and when an EPO or POS plan fits. Our guide to every plan type covers the rest.
Costs beyond the premium
A low premium is easy to see. In contrast, the cost of a narrow network shows up later, when you need care outside it. Then several things can stack up.
- Out-of-network care doesn't count toward your yearly out-of-pocket limit
- Providers outside the network can balance bill you
- Services your plan doesn't cover never count toward the limit either
- Premiums don't count toward the limit at all
For 2027 coverage, that yearly limit on ACA plans is $12,000 for one person and $24,000 for a family. Even so, the cap only protects in-network care. Learn how your yearly spending cap works before you choose a narrow plan.
Deductibles and premiums move together
Network size isn't the only lever. Generally, a plan with a lower premium also has a higher deductible, so you pay more when you use care. That means a narrow plan with a big deductible can feel cheap until you get sick. To weigh the two, read how deductibles and premiums trade off.
A licensed Vivna agent can check your doctors and hospitals in each plan's network, then compare yearly costs, at no cost to you.
A worked example: narrow vs broad health insurance networks
Here's a simple example with made-up sample prices, not a quote. Sam, 45, compares two plans from different carriers.
- $5,400 a year in premiums
- Sam's heart specialist is not in network
- Those visits get no coverage
- $6,720 a year in premiums
- Sam's specialist is in network
- Each visit has a $60 copay
How the year plays out
Sam sees the specialist 10 times. On Plan A, each visit costs the full $250 out-of-network price, so that's $2,500. In addition, none of it counts toward the out-of-pocket limit. On Plan B, the same visits cost $600 in copays.
Now flip it. If Sam's doctors were all in Plan A's network, Plan A would win by about $1,300 in premiums alone. So the right answer depends on your doctors, not on network size by itself.
Rules that protect you outside the network
Some federal rules limit the damage when you can't stay in network. First, plans can't charge higher copays or coinsurance for emergency care at an out-of-network hospital. Plans also can't require prior approval before you go to the ER.
Second, the No Surprises Act protects you from many surprise out-of-network bills. According to CMS, that covers emergency room visits and care tied to a visit at an in-network hospital, outpatient department or surgery center. It also covers air ambulance services. Even so, planned visits to an out-of-network doctor's office aren't protected.
A narrow network plan won't pay for routine care outside its network. So if you get an out-of-network specialist bill, that money won't count toward your yearly limit. Always confirm network status before a planned visit.
How to choose between health insurance networks
Start with the people you already see. Then let that list point you to the right network size.
A narrow HMO or EPO can lower your premium.
Check them first, then weigh a broader PPO.
Look for a network that covers both areas.
Pick the cheapest plan that includes it.
- List your doctors and hospital
Include specialists, your pharmacy and any planned surgery.
- Search each plan's directory
Use our doctor search links for every carrier. Then call each office to confirm.
- Compare yearly totals
Add 12 months of premiums to the care you expect to use.
Questions to ask about any network
- Are my doctors and my hospital in this exact plan?
- Which labs and imaging centers are in network nearby?
- Do I need referrals to see a specialist?
- Is there any coverage when I travel out of state?
Directories can lag behind real changes, so follow up by phone. Here's how to confirm a doctor takes your plan in a few minutes.
We see the same mistake every fall. Someone picks the lowest premium, then learns in March that their doctor isn't in the network. So give us your doctor list first. We'll check it against every plan before we talk price.
Each carrier's network is different. For example, see how the Oscar network works or how Ambetter builds its network. When you're ready, compare ACA and private plans in your ZIP code or call 888-730-6001.
Check the network before you check the price.The rule our licensed agents repeat most
Health insurance networks: FAQs
Why are narrow network plans cheaper?
Carriers can bargain for lower prices when they send more patients to fewer providers. Those savings show up as lower premiums. In fact, one study of Marketplace silver plans found narrow doctor and hospital networks cost about 16% less than broad ones. The trade-off is fewer choices, so check your doctors first.
Is a bigger network always better?
No. A bigger network costs more each month, so you pay for access you may never use. If all your doctors are in a smaller network, that plan may cost less for the year. However, if you see out-of-network specialists, a broader network can save you money overall.
Do provider networks affect my deductible?
Yes, in two ways. First, in-network care usually counts toward your deductible and out-of-pocket limit, while out-of-network care may not. Second, some PPO plans have a separate, higher deductible for out-of-network care. So staying in network keeps more of your spending working toward your cap.
Which network type has the lowest premiums?
HMO and EPO plans often have the lowest premiums, because they limit coverage to their own networks. PPO plans usually cost more but let you go out of network for an added cost. Still, prices vary by carrier and area, so compare real quotes for your ZIP code.
What happens if I need emergency care out of network?
Plans can't charge higher copays or coinsurance for emergency care at an out-of-network hospital. Also, the No Surprises Act protects you from many surprise bills for emergency care. After you're stable, though, your plan may ask you to move to an in-network hospital for ongoing care.
Are narrow network plans worth it?
They can be, when your doctors and hospital are already in them. In that case, you get the same care for a lower premium. On the other hand, if you rely on a specialist outside the network, the savings can disappear quickly. So list your providers, check each plan, and then compare yearly totals.
Vivna's licensed agents compare plans from 50+ carriers. Call Monday through Friday, 9am to 6pm.
Sources
- Health Affairs (2017): Marketplace network breadth and premiums
- HealthCare.gov: Health insurance plan and network types
- CMS: Your rights and protections against surprise medical bills
- HealthCare.gov: Out-of-pocket maximum/limit
- HealthCare.gov: Doctor choice and emergency room access
Vivna Insurance is a licensed, independent health insurance agency (NPN 19168641). We are not affiliated with HealthCare.gov or any government agency. Plan availability, networks and benefits vary by state and change over time.