Out-of-Network
Healthcare providers who don't have contracts with your insurance plan, usually resulting in higher costs.
What is Out-of-Network?
Out-of-network providers don't have contracts with your insurance company. This typically means higher costs for you, and in some cases, no coverage at all. The provider can charge whatever they want, and you're responsible for the difference between their charge and what insurance pays.
With PPO plans, you have out-of-network coverage but at higher cost-sharing - perhaps 60/40 instead of 80/20, with a separate (higher) deductible and out-of-pocket maximum. HMO and EPO plans generally don't cover out-of-network care except for emergencies.
Out-of-network providers can also "balance bill" you for the difference between their charges and your insurance payment. Some states have surprise billing protections for certain situations, but coverage varies.
Frequently Asked Questions
Will my insurance pay anything for out-of-network care?
It depends on your plan. PPOs offer out-of-network coverage at higher cost. HMOs and EPOs usually only cover emergencies out-of-network.
What is balance billing?
When an out-of-network provider bills you for the difference between their charge and what insurance paid. You may be responsible for this extra amount.
Are out-of-network costs HSA-eligible?
Yes. Qualified medical expenses are HSA-eligible regardless of network status. You'll just pay more out-of-pocket for out-of-network care.
Related Terms
In-Network
Healthcare providers who have contracts with your insurance plan to provide services at negotiated rates.
Balance Billing
When an out-of-network provider bills you for the difference between their charge and what insurance pays.
Preferred Provider Organization (PPO)
A health plan that offers flexibility to see any doctor, with lower costs when you use in-network providers.
Health Maintenance Organization (HMO)
A health plan that requires you to use in-network providers and get referrals for specialists.
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