What is a health insurance network?

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When it comes to selecting a health plan, it's important to know what a health insurance network is, how it impacts your care and how to find an in-network provider. Here’s what you need to know about the Wellmark provider network.

What is a network?

A health insurance network is a group of doctors, specialists, facilities and other medical providers who have an agreement with Wellmark to provide health care services. When a provider is in-network, they offer an in-network rate of payment to Wellmark members for the health services they provide.

The difference between in-network vs. out-of-network providers

You’ve probably heard that when you see a doctor or other health care provider, it’s important to use in-network providers and facilities. But why use an in-network provider? Using in-network providers reduces your out-of-pocket costs and can prevent unexpected bills. Staying in-network also ensures you have access to the care you need and your health insurance claims are processed quickly and efficiently.

Out-of-network providers and facilities do not have the same agreements with Wellmark that in-network providers do, meaning they don’t have to offer you an in-network rate for care — which can result in balance billing or denied claims. This could also mean more administrative work before and after receiving care.

However, the No Surprises Act protects you from surprise bills or balance billing when you receive emergency care from an out-of-network provider, as well as certain services from out-of-network providers at in-network facilities. If you do receive a surprise bill, you should contact Wellmark Customer Service and the No Surprises Help Desk for advice on how to resolve or dispute the bill.

Find an in‑network provider near you

Get the care you need — at the lowest cost — by choosing an in-network provider. Start your search now to connect with a trusted provider who fits your health needs and budget.

Find in-network care

Questions to ask about your health insurance network when choosing a plan

The type of network coverage and plans available to you can vary. If you have a choice between plans when considering your health insurance options, ask yourself the following questions.

These questions can help you choose

Do I have an in-network provider I want to continue seeing?

It’s easy to check if your providers are in-network with Wellmark, even if you’re not a member. If you're a Wellmark member, you can quickly see if your current doctor is in-network by logging in to myWellmark^®. In most cases, you’ll find your provider is in-network. If your provider isn’t in-network, you’ll need to select a new in-network provider or pay more out-of-pocket for any care you receive from them.

I’m a Wellmark member. How do I search for in-network providers?

When you log in to myWellmark, you can search for in-network providers and access your benefits documents to learn how your plan covers in-network vs. out-of-network care. Register for myWellmark today.

Do I need to see an in-network provider for my expenses to be covered?

It depends on your health plan. While some plans cover out-of-network care with higher cost-sharing, others only cover in-network care. If you’re a member, you should check your benefit details on myWellmark before receiving care. Out-of-network care is always covered in the case of emergency, even when you’re outside your plan's service area.

Do I need to select a PCP before my coverage begins?

It depends on your specific health plan details. If you have a Wellmark Blue HMO^SM or Wellmark Blue POS^SM plan, you are required to designate a PCP. And even if you aren’t required to designate a PCP, you should still consider choosing one to manage your care, refer you to in-network specialists and help with the prior authorization process.

Which hospitals can I use?

If you’re a Wellmark member, you can search for in-network health facilities on myWellmark to determine which local hospitals are in-network. Even when you visit an in-network facility, you’ll still need to make sure the providers you see at that facility are in-network to avoid higher out-of-pocket costs.

How do I make sure specialist providers are covered?

If you want the freedom to see any doctor or specialist, a PPO plan may be a good fit for you. While Wellmark doesn’t require you to have a referral to see specialists in the HMO network, some specialists do require them — which can take time.

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Why out-of-network care costs more

You may already know care can cost more when you go out-of-network, but do you know why? Here are a few reasons:

You see a health care provider who does not contract or work with Wellmark and, as a result, they can’t offer the in-network rate.
Depending on the health service and your benefits, you may have to pay coinsurance instead of a copay — or sometimes both. Coinsurance is a percentage of the total covered charges, while a copay is a set amount you pay for covered services. Coinsurance can cost much more depending on the services you receive and your health insurance plan benefits.
Many plans have a maximum amount they will reimburse for out-of-network services. You may have to pay the difference between this amount and the total cost of care.

Explore how your plan uses the Wellmark provider network

If you’re already a Wellmark member, you can browse in-network providers and find detailed cost and claims information on myWellmark. Or you can call customer service at 800-524-9242 (TTY: 888-781-4262), Monday-Friday, 7:30 a.m. to 5:00 p.m., Central Time.

Everyone's needs are different. For more help on the plans available to you and the best plan to fit your needs, find an authorized Wellmark agent near you.

Disclaimers

*Wellmark PPO and POS plans are only available through select employers.

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