What is a Provider Network?

You may have heard that premiums, copays and deductibles are all things you need to consider when choosing the best health plan for you or your family. Did you also know you should think about the plan’s provider network? Here's why.

1. Health plans save you money by negotiating discounts on health care charges with doctors, hospitals and other health care providers. When a provider agrees to take patients with a health plan, they agree to accept a lower fee for their care.
2. Some plans’ provider networks have fewer doctors and hospitals than others. The plan offers lower costs to the member because they pay less to providers who see plan members. That means fewer providers agree to be in the plan’s network. It also means that smaller networks offer fewer choices of doctors you can use when you need care.
3. You can lower your out-of-pocket costs by using doctors and other health care providers in your plan’s network. If you visit a doctor outside your network, you may have to pay more for your care. In some cases (such as HMO plans), you may have to pay the full cost when you go out of network. If your family uses certain doctors, specialists, hospitals and urgent care centers, make sure they are in the network of any health plan you consider.

Provider Networks: HMO vs PPO

While there are other types of health plans, the two most common are HMOs and PPOs. An HMO may have lower monthly premiums, but you'll choose a primary care physician (PCP) to direct your care within the network. You'll need a referral from your PCP to see a specialist. In a PPO plan, you may pay a higher premium. But have more freedom to choose doctors and hospitals without a referral.

Because this can be a big factor in your medical visits, here are some questions to consider as you choose your health plan:

• Is it important to have a lot of doctors and hospitals I can choose from?
• Is it worth paying a higher monthly premium to  have more provider choices?
• Are the providers I often go to in my chosen plan’s network?

Insider’s Tip: Use the BCBSNM Provider Finder^® online tool to see doctors, hospitals and urgent care centers that are in network for the plan you are considering. Provider Finder is also the place to check for doctors and any specialists you need to see after you have coverage.

Originally published 10/02//2018; Revised 2020, 2022, 2024