Medically reviewed by Kevin Wandler, MD, Chief Medical Advisor
When you start looking for addiction or mental health treatment, you’ll quickly run into two phrases: in network and out of network. The difference can change what you pay by a wide margin, and sometimes whether your plan pays anything at all. Understanding these terms before you choose a treatment center helps you avoid unexpected bills and make a decision you feel good about.
What In Network Means
A provider is in network when it has signed a contract with your health plan. In that contract, the provider agrees to accept a negotiated rate for its services, and the plan agrees to pay its share of that rate according to your benefits.
For you, in-network care usually means:
- Lower costs, because your deductible, coinsurance and copays are based on the negotiated rate
- Protection from being billed for the difference between the provider’s full charge and what your plan allows
- Your payments counting toward your in-network out-of-pocket maximum
- A more predictable prior authorization and billing process
What Out of Network Means
An out-of-network provider has no contract with your plan. Depending on your plan type, the plan may pay a smaller share of the cost, apply a separate and often higher deductible, or pay nothing at all for non-emergency care.
Out-of-network providers can also bill you for the difference between their charge and the amount your plan considers allowable. This is called balance billing, and it can add up quickly for services that last days or weeks, such as residential treatment. Some plans have a separate out-of-network out-of-pocket maximum, and some have no cap at all for out-of-network care.
How Your Plan Type Affects Your Choices
The letters on your insurance card offer clues about how flexible your network is:
- HMO (health maintenance organization): generally covers only in-network care, except in emergencies, and may require referrals.
- EPO (exclusive provider organization): generally covers only in-network care except in emergencies, usually without referrals.
- PPO (preferred provider organization): covers both in-network and out-of-network care, with lower costs in network.
- POS (point of service): blends HMO and PPO features, often with referrals for out-of-network care.
What Surprise Billing Protections Cover
A federal law called the No Surprises Act protects many people from unexpected out-of-network bills in certain situations, such as emergency care and some services from out-of-network clinicians at in-network hospitals and certain other facilities. It generally doesn’t apply when you knowingly choose an out-of-network provider for planned treatment. If you’re uninsured or paying on your own, you have the right to a good faith estimate of expected charges before scheduled care.
Comparing Costs Side by Side
If you’re weighing an in-network program against an out-of-network one, ask your plan the same set of questions about each so you can compare them fairly:
- What deductible applies, and how much of it have I already met?
- What coinsurance or copay applies to each level of care?
- Is there an out-of-pocket maximum for this provider, and do balance-billed amounts count toward it?
- Will the plan pay based on the provider’s charge or on its own allowed amount?
It also helps to ask each treatment center for a written estimate. Seeing the figures side by side often makes the choice clearer, and it lowers the chance of an unexpected bill arriving weeks after treatment ends.
When Out-of-Network Coverage Might Be Possible
Sometimes a plan doesn’t have an in-network provider that can deliver the level of care a person needs within a reasonable distance or time. In those cases, a plan may agree to cover an out-of-network provider at in-network cost sharing through what’s often called a network gap exception or a single case agreement. These arrangements aren’t automatic and depend entirely on the plan, but they’re worth asking about if you’ve been told no in-network option exists.
Network Status Isn’t the Only Factor
Cost matters, but it isn’t the only thing to weigh. When comparing programs, also consider:
- Whether the program offers the level of care you need, from medical detox through outpatient support
- Whether it treats co-occurring mental health conditions alongside substance use
- Accreditation, such as accreditation from The Joint Commission, which Promises Dallas-Fort Worth holds
- Whether it plans for aftercare so support continues after discharge
Promises DFW offers medical detox, residential treatment, an in-person partial hospitalization program and a virtual intensive outpatient program, with aftercare planning for every client.
How to Confirm Network Status
Online provider directories are a starting point, but they can be out of date. A more reliable approach is to call the behavioral health number on your insurance card and ask whether a specific facility, at its specific address, is in network for your specific plan. Insurers often sell many products under one brand name, and a facility can be in network for some and not others.
Promises Dallas-Fort Worth is in network with a range of plans, including Aetna and its affiliates Meritain Health and First Health Network, and UnitedHealthcare and affiliates such as Optum, UMR and Oxford. Our free, confidential insurance verification confirms how your plan applies.
Frequently Asked Questions
Is in-network rehab always cheaper?
Usually, but not always. Your deductible, coinsurance and out-of-pocket maximum all play a role, and verification shows your likely costs for each option. Our cost of rehab page explains more.
Can a facility be in network with my insurer but not my plan?
Yes. Insurers offer different products, such as Marketplace plans, employer plans and Medicaid plans, and these can have different networks.
What happens if my plan changes during treatment?
Let the treatment center know right away. A new plan may have different network rules and may require a new authorization.
Check Your Network Status Today
See every plan we work with on our insurance options page, reach out online, or call (469) 546-9303. Our admissions team is available 24/7.