Health Insurance

Out-of-Network Insurance Guide

Out-of-Network Insurance Guide

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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, and this type of coverage is worth it for people who want to maximize their health care choices or who have specialized medical needs.

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.

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 family preferred provider organization (PPO) 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 insurer 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 insurer 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

  1. You choose an out-of-network provider because of their specialized expertise or your personal preference
  2. You need medical care while traveling
  3. You have a medical emergency and the nearest health care provider is out of network
  4. 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.

You may be protected from these high medical costs if your insurance plans offers access to out-of-network hospital emergency services at the same rates as in-network hospitals. This protection is in place for all health plans available through the insurance marketplace.

However, the billing process for your total care can still leave you with unexpected costs because associated services during your emergency may be out of network. For example, you could have been admitted to an out-of-network hospital that accepted your insurance, but the policy might only cover the cost of an inpatient hospital bed. All other services that you receive during your stay could be billed out of network and cost you thousands of dollars.

How will out-of-network emergency care change in 2022?

In December 2020, bipartisan legislation called the No Surprises Act was passed to protect consumers from surprise out-of-network bills. Going into effect on January 1, 2022, H.R. 133 will require health insurance companies to cover emergency services at in-network rates and stop balance billing practices.

Plus, any out-of-network payments for emergency care will count toward in-network deductibles and out-of-pocket maximums. There are also added consumer protections when a provider leaves a network, and insurance companies must regularly update online network directories and provide 90 days of transitional coverage.

Is out-of-network coverage worth it?

There are three reasons to choose a plan with out-of-network coverage:

  1. 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.
  2. 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.
  3. 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 28% of individual plans offer out-of-network benefits, according to a 2018 report by the Robert Wood Johnson Foundation. This rate has been declining and is likely to be even lower today.

Even with the health plans that have out-of-network coverage, you're likely to still have significant financial responsibility for out-of-network costs because the deductibles are very high. The median out-of-network deductible is $12,000, and about 30% of plans have an out-of-network deductible higher than $20,000 before the insurance company starts contributing to health care costs.

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:

  1. Compare insurance policies to choose a plan that has the best network for your needs.
  2. Before seeking health care, check that the provider is listed on the plan's network.
  3. Contact your insurer to confirm questions about coverage, cost, deductibles and referrals.
  4. Use a health savings account to financially prepare for surprise health care expenses.
  5. 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.

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.