Does Out of Network Mean Out of State?

The terms “out-of-network” and “out-of-state” are often confused in health insurance discussions. While both relate to where and from whom you receive healthcare services, they represent distinct aspects of your coverage. Understanding the differences between a provider’s network status and your geographic location is important for managing healthcare costs and ensuring access to care.

Understanding Provider Networks

A health insurance provider network consists of doctors, hospitals, pharmacies, and other healthcare facilities that contract with an insurer. These “in-network” providers agree to offer services at negotiated, discounted rates to members. When you receive care from an in-network provider, your out-of-pocket costs, such as copayments, deductibles, and coinsurance, are lower because the insurer pays a larger portion of the expenses.

Conversely, “out-of-network” refers to healthcare providers who do not have a contract with your health insurance plan. Seeking care from these providers results in higher out-of-pocket costs, and sometimes your plan may not cover services. Out-of-network providers can bill you for the difference between their full charges and what your insurance plan pays, a practice known as balance billing. Health plans like Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs) limit coverage to in-network providers, except in emergencies. Preferred Provider Organizations (PPOs) and Point of Service (POS) plans offer some coverage for out-of-network care, but at a higher cost to the member.

Understanding Geographic Coverage

Geographic coverage, often referred to as a health plan’s “service area,” defines the region where the insurance plan operates and provides benefits to its members. “In-state” means receiving care within the state where your insurance policy was issued or where the primary policyholder resides. This is the primary area where your plan’s network of providers is concentrated.

“Out-of-state” care refers to medical services received outside this primary service area. Geographic location is a separate consideration from a provider’s network status. Common scenarios for needing out-of-state care include travel, college students attending school in a different state, or seasonal residents who spend parts of the year in different locations. While some plans have broader national networks, many individual market plans have localized networks, making out-of-state routine care challenging.

When Networks and Geography Intersect

The terms “out-of-network” and “out-of-state” are not interchangeable, although they can overlap. An in-state provider can be out-of-network if they do not have a contract with your health plan, even if located within your plan’s service area. For instance, a specialist in your hometown might not accept your insurance.

Conversely, an out-of-state provider could still be considered in-network, especially with plan types like PPOs that have national networks or through travel networks. Employer-sponsored plans may offer nationwide networks for employees who travel or reside in multiple states. However, an out-of-state provider can also be out-of-network, which results in the highest out-of-pocket costs as both geographic and network limitations apply.

For emergency medical services, most health insurance plans are required to cover care regardless of whether the hospital or provider is in-network or out-of-network, or if the emergency occurs out-of-state. Insurers cannot charge more for emergency room services at an out-of-network hospital than they would for an in-network facility. However, once the emergency is stabilized, any follow-up care or non-emergency treatment may revert to the plan’s standard network rules, potentially leading to out-of-pocket expenses if care continues out-of-network or out-of-state.

Navigating Your Health Plan

To determine your coverage for both in-network and out-of-network services, as well as for care received out-of-state, begin by reviewing your health plan’s documents. The Summary of Benefits and Coverage (SBC) is a standardized document required for all health plans, outlining costs, benefits, and coverage limitations in an easy-to-understand format. This document should indicate your deductibles, copayments, and coinsurance for both in-network and out-of-network care.

Contacting your insurance provider directly is a reliable way to confirm coverage details. You can call the member services number on your insurance card. When speaking with a representative, ask questions, such as whether you have out-of-network benefits, what your coverage is for out-of-state care, and the process for emergency care when traveling. For planned out-of-network or out-of-state services, it is often necessary to obtain pre-authorization from your insurer. This process involves your provider submitting information to your health plan for approval before you receive care, to ensure coverage and rate.