What does it mean if you are out of network?


Editorial team Published on

An out-of-network provider or facility is a doctor, hospital, or clinic that does not have a contract or agreement with your health insurance plan.

Because they lack a contract, they do not accept your insurer's pre-negotiated, discounted rates.

Key Impacts of Out-of-Network Care

  • Higher Costs: You usually pay much more, or even the entire bill, because your insurance pays a smaller share or nothing at all.
  • Balance Billing: An out-of-network provider can charge you the difference between their total fee and what your insurance decides to reimburse (called balance billing).
  • Plan Restrictions: Plans like HMOs (Health Maintenance Organizations) generally offer zero non-emergency coverage out-of-network. Plans like PPOs (Preferred Provider Organizations) may cover some costs, but at a much higher out-of-pocket rate.
  • Emergency Exception: By law under the No Surprises Act, true emergency care is covered at in-network rates even if the facility or doctor is out-of-network.

How to Check Status

  • Look at your insurer’s online directory or mobile app.
  • Call the phone number on the back of your insurance card.
  • Contact the doctor's office directly and ask if they take your specific plan.