Out-of-Network Insurance Guide
Out-of-network providers are the doctors and facilities that do not have a direct affiliation with your health insurance company.
Out-of-network care, either through a physician visit or during an emergency, is usually more expensive. Getting a health insurance plan with out-of-network coverage can help you avoid some surprise medical bills. This type of coverage is worth it for people who want to maximize their health care choices or who have specialized medical needs.
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What does out-of-network health care mean?
Out-of-network health care refers to the physicians, facilities and treatment options that are outside of your health insurance company's group of affiliated providers. Even if a provider is fully licensed and recognized in their field, if they don't have a relationship with the insurance company, they're considered out of network.
Each insurance company has a different health insurance network with a unique group of affiliated doctors. If you receive care that's outside of these providers, your health care service is considered out of network.
How much does out-of-network healthcare cost?
In most cases, you'll pay more out of pocket for health care received from an out-of-network provider. Each health insurance plan is different, and your policy will explain how much you pay for in-network care versus out-of-network care.
For example, on a sample PPO (preferred provider organization) insurance plan, a visit to an in-network specialist has a $50 out-of-pocket cost. However, if you go to an out-of-network provider, you would pay 40% of the total bill with this insurance plan.
How does coverage work?
Understanding a health insurance network can help you avoid high out-of-pocket costs or surprise bills. Here's what to know about how out-of-network coverage works:
- Your policy explains the out-of-network coverage rates: Your cost for out-of-network healthcare will be higher because these medical providers do not have a pricing contract with your health insurance company. Each policy and type of care will have a different cost breakdown. By reviewing the details of your policy, you can learn how your out-of-pocket costs for in-network health care compare to what you'll pay for out-of-network health care.
- Your insurance plan will list its network of providers: Each health insurance company has an online directory of in-network providers. Before purchasing a health insurance policy, you can save money by checking the online directory to see if your preferred doctors and hospitals are included within its network.
- You're responsible for choosing in-network or out-of-network services: Before seeking any health care, you can avoid unexpected costs by checking if your doctors and facilities are in a health insurer's network. It's up to you to know if your health care will be charged at in-network rates or out-of-network rates. Because an insurance company's network can change throughout the calendar year, it's a good idea to double-check the directory or call your insurance company if you have any questions.
- Out-of-network care may be excluded from deductibles or out-of-pocket maximums: With some health insurance plans, out-of-network expenses may be excluded from the policy's structural benefits. In these cases, what you spend on out-of-network health care may not count toward your deductible or out-of-pocket maximum. This could create a financially risky situation where you could be responsible for the full cost of your out-of-network health care without any limitations.
- Out-of-network costs may have a different billing and reimbursement process: For some insurance companies, out-of-network claims are handled differently. You may be billed directly for these health care services and may have to submit a claim to the insurance company. Any out-of-network reimbursement is then issued directly to you, or you can request that it's sent to the health care provider.
Top four reasons for getting out-of-network health care
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You choose an out-of-network provider because of their specialized expertise or your personal preference
- You need medical care while traveling
- You have a medical emergency and the nearest health care provider is out of network
- Your in-network provider uses out-of-network auxiliary services such as lab tests or anesthesia
How is out-of-network coverage affected by the type of insurance plan?
The type of health insurance plan can affect how in-network and out-of-network coverage is treated. In general, PPO plans offer both in-network and out-of-network care, but your costs are higher when you go out of network. On the other hand, health maintenance organization (HMO) and exclusive provider organization (EPO) plans only offer in-network care, and out-of-network care will not be covered.
Plan type | In network | Out of network |
|---|---|---|
| PPO | ||
| POS | ||
| HMO | ||
| EPO |
Covered
Covered but with higher costs
Not covered
For example, one UnitedHealthcare HMO plan from the health insurance marketplace does not include out-of-network coverage. You would get the benefits of the plan if you visited doctors or facilities within the insurer's network. However, getting health care services from a provider outside the network would mean you're responsible for the full cost of health care out of pocket.
How can an insurer's network affect emergency care?
Out-of-network care during an emergency can lead to high medical bills. There are some protections in place, but there are also some loopholes that can impact how much you have to pay.
During a medical emergency, you'll likely be treated at the nearest hospital or urgent care center, whether it's within your insurer's network or not. This can frequently result in out-of-network services, and the American Bar Association reports that about one out of every five emergency room visits involves out-of-network care.
- In general, you can't be charged out-of-network rates during an emergency. That's because you should go to the closest hospital to get medical care, instead of trying to find an in-network hospital.
- But some patients are still getting billed for out-of-network emergency care. For example, an emergency surgery may not be labeled as an "emergency" if you didn't get admitted through the ER. This means you'd need to file an appeal to have the bill reviewed, rather than it being paid automatically.
How did the No Surprises Act change out-of-network emergency care?
The No Surprises Act, which went into effect on Jan. 1, 2022, requires health insurance companies to cover emergency services at in-network rates. That means you won't have to pay more if you go to an out-of-network emergency room.
If you have to pay for some of your emergency care yourself, it will count toward your in-network deductible and out-of-pocket maximum. There are also added protections when a medical office leaves a network. And insurance companies must regularly update online network directories and provide 90 days of transitional coverage so you have time to find a new in-network doctor if your prior doctor leaves the network.
Is out-of-network coverage worth it?
There are three reasons to choose a plan with out-of-network coverage:
- Protect yourself from unexpected medical costs: Some level of out-of-network coverage can help protect you from the worst-case scenario where large medical bills lead to bankruptcy.
- Access care for specialized health needs: If there are a limited number of doctors or facilities that treat your medical condition, having out-of-network coverage can give you better health care access.
- Maximize your choices: Having out-of-network coverage gives you the most options when choosing your doctors and health care providers.
Choosing an insurance plan with out-of-network coverage won't be a priority for everyone, and even when you don't need a policy with these expanded benefits, you can still protect yourself by choosing a large health insurance company that has a broad network of doctors. This reduces the chance that you'll need to go out of network for your health care and pay the associated costs.
For example, Blue Cross Blue Shield has in-network providers in all 50 states, and its network includes 90% of doctors and specialists. Even if you're traveling in a different state, you may still be able to find an in-network provider.
How hard is it to find health insurance with out-of-network coverage?
In the health insurance marketplace, only 17% of individual plans offer out-of-network benefits.
That includes PPO (preferred provider organization) and POS (Point of Service) plans, which have out-of-network coverage.
Even when plans with out-of-network coverage are available, they usually cost more than plans that only have in-network coverage.
The average cost of a PPO plan is $102 more per month than an HMO plan which doesn't have out-of-network coverage.
What steps can you take to protect yourself from surprise medical bills?
Research and planning can help you protect yourself and your family from the high cost of out-of-network health care. Here's what you can do:
- Compare insurance policies to choose a plan that has the best network for your needs.
- Before seeking health care, check that the provider is listed on the plan's network.
- Contact your insurer to confirm questions about coverage, cost, deductibles and referrals.
- Use a health savings account to financially prepare for surprise health care expenses.
- When an insurance network doesn't include any local providers who offer the service you need, request a network gap exclusion before receiving out-of-network care.
Frequently asked questions
Which is better, in-network or out-of-network health care?
In-network health care generally costs less than going to a doctor or facility that's out of network. In-network providers have a pricing arrangement with your insurance company, and as a result, you'll pay less out of pocket.
Why does in-network or out-of-network health care matter?
Only some doctors and health care facilities will be a part of your insurance company's network of providers, and you'll spend less to get health care with these in-network providers. If your insurance company has a bigger network of providers, you'll have more choices when seeking affordable health care.
Which insurance plans let you go out of network?
PPO and point-of-service (POS) health insurance plans generally offer some level of out-of-network coverage. In contrast, HMO and EPO insurance plans are usually limited to just in-network providers and offer no out-of-network coverage.
Sources and methodology
Costs and plan availability is based on 2025 ACA marketplace plans.
Plan information was gathered from Centers for Medicare & Medicaid Services (CMS) public use files (PUFs) and state-run marketplaces. Data is not comprehensive of all plans, and is based on plan data that's available. Learn more about our health insurance methodology
Editorial note: The content of this article is based on the author's opinions and recommendations alone. It has not been previewed, commissioned or otherwise endorsed by any of our network partners.