What Does Out of Network Mean for Health Insurance?

“Out of network” in health insurance refers to healthcare providers who do not have a contractual agreement with an individual’s health insurance plan. This means they have not agreed to accept the insurer’s negotiated rates for services. When a provider is out-of-network, it has significant implications for how medical services are covered and paid for by the insured.

Identifying Network Status

Determining a provider’s network status is crucial before receiving services. The most common method is to check your health insurance company’s official website. Insurers typically provide an online provider directory or a “find a doctor” tool where you can search for in-network professionals and facilities using your specific plan details.

You can also call your insurance company directly using the member services number on your ID card. A representative can confirm network status for the exact services you need. It is also advisable to contact the healthcare provider’s office staff to verify their network status with your plan. Always cross-reference this information with your insurer for the most accurate details. For comprehensive procedures, verify the network status of all parties involved, including surgeons, anesthesiologists, labs, and the facility itself, as they may not all be affiliated with the same network.

Understanding Out-of-Network Costs

Receiving care from an out-of-network provider typically results in higher financial responsibility for the insured individual. You may face higher or separate deductibles, meaning you pay more out-of-pocket before coverage begins. Coinsurance percentages are also generally much higher for out-of-network care, requiring you to pay a larger percentage of the service cost after your deductible is met. For example, an in-network service might have a 20% coinsurance, while an out-of-network service could be 50% or more.

A significant financial risk with out-of-network care is “balance billing.” This occurs when the provider charges you the difference between their total fee and the amount your insurance company pays. Unlike in-network providers who agree to accept the insurer’s negotiated rate as full payment, out-of-network providers are not bound by such agreements and can bill you for the remaining balance. Depending on your health plan type, such as an HMO or EPO, out-of-network services might not be covered at all, except in emergencies. While in-network care usually has an out-of-pocket maximum, out-of-pocket maximums for out-of-network costs may be higher or may not apply at all, potentially leading to unlimited financial exposure.

Steps for Out-of-Network Care

When out-of-network care is necessary, taking proactive steps can help manage costs. For planned procedures or when a specialized provider is not available in-network, you can seek “prior authorization” or a “network exception” from your insurer before receiving care. This involves demonstrating medical necessity and that an in-network alternative is unavailable, potentially allowing the service to be covered at in-network rates. A “gap exception” is a type of network exception that aims to have the insurer cover an out-of-network provider at an in-network rate due to a network deficiency.

If your out-of-network provider does not submit claims directly to your insurer, you will need to submit the claim yourself for reimbursement. This process requires obtaining an itemized bill, often called a “superbill,” from the provider and completing a claim form.

If you face substantial out-of-network bills, consider negotiating directly with the provider. Many are open to discussing payment plans or reduced fees. If your insurer denies or limits coverage, you have the right to appeal their decision. This involves submitting a written appeal with supporting medical documentation.