We define common health coverage terms on our websites and in our materials. But technical definitions may not always fully explain some concepts.

Each article in our What Does It All Mean series is looking at a few health care benefit terms in more depth. This month we look at two terms that can be key to getting the best value from your benefits.

In-Network

The Official Definition

Services provided by a physician or other health care provider with a contractual agreement with the insurance company and paid at a higher benefit level.

Let’s Break That Down

  • The provider (doctor, clinic, hospital, pharmacy) signed a contract with Blue Cross and Blue Shield of New Mexico (BCBSNM).
  • The contract spells out what the provider will charge for services for our plan members.
  • These providers cannot charge more than their contract permits.
  • These providers cannot bill you for any difference between what their contract permits and what they may charge others who are not our plan members.
  • To find out which providers are in-network for your plan, log in to Blue Access for Members and click on Find a Doctor or Hospital. This will take you to the Provider Finder tool.

Example

  • PPO members can go to out-of-network providers, BUT they may pay higher out-of-pocket costs for their visit or service.
  • HMO members are not covered for care they receive from providers who are not in-network.

In-Network Tip

In some cases, not all providers in a practice group are part of the same network. If you are offered an appointment with a provider you don’t usually see, ask if the provider is in your network or call the number on the back of your member ID card to confirm.

Non-contracting Hospital

The Official Definition

A hospital that has not contracted with a particular health care plan to provide hospital services to members in that plan.

Let’s Break That Down

  • Not all hospitals contract with BCBSNM. Some hospitals may be part of a larger group of hospitals that contract with other health plans, or they may have decided not to meet some requirement of contracting with BCBSNM.
  • Some in-network providers still have relationships with non-contracting hospitals. Providers often have relationships with more than one hospital. For example, they may have admission privileges, meaning they can admit someone to that hospital and treat them there, with several hospitals.

Example

  • Your in-network doctor works with Hospital A and Hospital B.
  • He decides you need a test that must be done at a hospital.
  • Hospital A is in your network.
  • Hospital B is not.

Non-Contracting Hospital Tip

Ideally, your doctor knows which hospitals are contracted with your plan and will set up the test at Hospital A. But if your doctor chooses Hospital B for some reason, ask to be scheduled at Hospital A instead.