Which statement best describes an out-of-network provider?

• A. A provider that participates in the plan
• B. A provider that is within the plan’s network
• C. A provider that does not participate with the plan
• D. A provider who only treats emergencies

Answer: (C)

This item tests your understanding of what it means for a health plan to have providers in-network versus out-of-network. An out-of-network provider is someone who does not have a contract with your insurance plan. Because there’s no agreement on negotiated rates, the plan typically covers a smaller portion of the bill and you may be responsible for a larger share, including higher out-of-pocket costs or balance billing. The idea is that providers in the plan’s network have agreed to set prices with the plan, making it cheaper for you to receive care.

So the statement that best describes an out-of-network provider is that it does not participate with the plan. The other ideas describe in-network providers (those who participate in the plan or are within the network) or describe a situation (emergency treatment) that doesn’t define network status.