Out-of-Network

Out-of-network refers to doctors, hospitals, and other providers that do NOT have a contract with your health insurance plan. Because there’s no pre-negotiated rate, you’ll pay significantly more for their services — and on some plan types, your insurance may not cover out-of-network care at all.

How out-of-network care is handled depends on your plan type:

PPO: Out-of-network care is covered, but at a higher cost share. You may also have a separate, higher out-of-network deductible.
HMO / EPO: Out-of-network care is generally not covered except in emergencies.
POS: Out-of-network care is covered with a referral from your PCP, but at a higher cost.

Going out-of-network can also expose you to balance billing — where the provider charges you the difference between their full rate and what your insurer pays. The No Surprises Act limits balance billing in many emergency situations, but gaps still exist for non-emergency out-of-network care.

Frequently Asked Questions

Am I covered if I go to the emergency room and it’s out-of-network?

Yes — emergency care is always covered, even out-of-network, on any ACA-compliant plan. Federal law requires it. However, you may still owe cost-sharing based on in-network rates, and you could be balance-billed for the difference in certain situations. The No Surprises Act provides some protections here, but reviewing your EOB after an emergency visit is always a good idea.

Do out-of-network costs count toward my out-of-pocket maximum?

Your out-of-network costs usually do NOT count toward your in-network out-of-pocket maximum on most plans. Some plans have a combined in-and-out-of-network out-of-pocket max, but many separate them. Check your plan’s Summary of Benefits carefully — this distinction can make a significant financial difference.

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