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What is Out of Network Insurance?

September 6, 2023

Woman calculating out of network costs on a computer

Having a health insurance plan is crucial for all of us and our overall well-being. It can provide financial assistance during unexpected medical emergencies and can also cover preventive care expenses. Health insurance plans can reduce the burden of the cost of medical care and ensure access to quality healthcare services. However, simply having health insurance is not enough. It's equally important to understand the coverage of your policy, including the benefits, limitations, and out-of-pocket costs. This includes the cost associated with using your insurance coverage when you're out of network. If you're wondering, "What is out-of-network insurance?", we're here to help. In this blog, we'll provide a complete guide to out-of-network insurance and how it works.

What is out of network insurance?


Out-of-network insurance coverage refers to the healthcare services that are not covered by your health insurance provider. This means that if you receive medical treatment from a provider who is not in your insurance plan's network, you may end up paying more for your medical expenses. Out-of-network coverage is a term that applies to both HMO, POS, and PPO health insurance plans. You will always need to review your insurance policy to understand your out-of-network benefits as well as their restrictions.

When you use out-of-network coverage for medical services, you have to pay more money for those services compared to in-network services. Your out-of-pocket expenses may include high deductibles, copayments, and coinsurance charges. In some cases, the out-of-pocket expenses for out-of-network services can be much higher than for in-network services. Therefore, you have to know what your out-of-pocket expenses are for out-of-network treatment before you seek medical services from an out-of-network provider.

When considering, "What is out-of-network insurance?" it's advised that you always double-check with your health insurance provider to confirm whether a provider or facility is in-network or out-of-network prior to going in for your appointment. If you have questions about your out-of-network coverage benefits or restrictions, be sure to ask your insurance provider or human resources representative to provide more information. By being aware of your out-of-network coverage, you can make informed decisions regarding your healthcare and avoid any unpleasant surprises regarding expenses that you thought would be covered.

What expenses are associated with out-of-network providers?


When seeking medical care from a healthcare provider who is not within your insurance network, you'll usually be responsible for paying much more of the cost than you usually would. This is because insurance companies typically have arrangements with providers who participate in their network, offering discounted rates to their policyholders. Out-of-network providers do not have these agreements, which means they can charge more for their services. In these cases, insurance usually covers a smaller percentage of the cost, with the patient being responsible for the remainder.

When answering the question, "What is out-of-network insurance?", we need to discuss fees. In addition to a higher rate for services provided by an out-of-network provider, patients may also be subject to additional fees not covered by their insurance. For example, some healthcare providers may charge “balance billing” fees, which are essentially charges for the difference between the provider’s standard rate and the amount the insurance company agrees to cover. Other costs patients may incur include deductibles, copays, and coinsurance, which can quickly add up and cause a financial burden for the patient.

You need to review any bills received from an out-of-network provider to ensure accuracy and negotiate payment plans if necessary. Charity care is one option, which is offered by many hospitals and clinics, providing free or discounted care to patients who cannot afford to pay for medical treatment. The criteria for eligibility varies depending on each institution, but patients may have to demonstrate that their income and expenses meet a particular threshold.

Along with charity care, in some instances, hospitals may also offer payment plans that can help manage the cost of out-of-network medical care. Payment plans involve revolving payment schedules where patients pay small amounts monthly, making it feasible to cover substantial medical expenses over time. In most cases, payment plans come with zero or low interest rates, so it's an affordable option for those who cannot pay for the entire expense upfront

When might you need to see an out-of-network doctor?


Sometimes, medical emergencies can happen without any prior notice or you may not have access to an in-network healthcare provider. You might need to see a healthcare provider who isn't part of your insurance network. When this happens, you'll be glad you know the answer to the question, "What is out-of-network insurance?" You may have to pay for the costs out of pocket, which can be expensive but can occasionally be unavoidable. Some of the most common reasons people see out-of-network healthcare providers include:

  • Being unable to obtain the service required through an in-network provider. If you need a specialized surgery or treatment that isn't covered by your insurance, you may need to seek out an out-of-network provider who specializes in that area. In such cases, you may end up paying more out of your pocket, but it could be worth it for the specialized care you receive.
  • You may be traveling or outside your insurance's coverage area. In such cases, you may need to seek care from a provider who is not in your network. You will pay more for your care, but it could be required to get the treatment you need when you're away from home.
  • You're facing long wait times or delays in getting an appointment. While there is a higher cost, it could be worth it for the quality of care you receive and for avoiding delays in getting the care you need.

Generally, seeing an out-of-network healthcare provider should be a last resort. Before choosing to do so, take the time to research your options and understand the costs involved. If possible, try to schedule appointments with in-network providers as they'll likely offer more affordable care. Still, in certain circumstances, out-of-network care may be needed and you need to be prepared in case this happens.

How can you choose the right health insurance for your needs?


Now that you have a better idea of how to respond to the question, "What is out-of-network insurance?" let's talk about finding the right plan. Choosing the right health insurance plan can be challenging, especially when it comes to managing the costs of out-of-network coverage. With careful consideration, you can make informed decisions on managing these out-of-pocket costs. First, carefully review the different insurance plans available to assess their out-of-network coverage limits. Plans with more comprehensive coverage may often have higher premiums, but it's essential to consider the long-term cost-benefit analysis before deciding on a plan.

Of course, you should try to check that your current healthcare providers are included in your preferred plan's network to avoid unexpected bills, so you can minimize the amount of money you need to spend seeing out-of-network providers. It's also wise to determine the plan's out-of-pocket maximum limit, which defines the amount you'll need to pay out of pocket for healthcare services. When you can't access a provider within your network, then attempt to negotiate billing for any out-of-network services. In extreme cases, you can even opt to appeal for a waiver of the out-of-network costs with the insurance company.

In the event that your preferred healthcare provider is not within the network, inquire about the costs associated with out-of-network care. In addition, check to see if the plan offers a “point-of-service” (POS) option, which allows you to visit out-of-network providers at a higher cost. By doing your research, you can find the right insurance plan that meets your needs and helps you manage the costs of out-of-network coverage effectively. Though it may take some time and effort, you should be able to access the care you need.

After reading this article, when someone asks you, "What is out-of-network insurance?", you'll be ready to respond. You need to understand your health insurance plan's out-of-network coverage as it can save you from potential financial strain. Sometimes an out-of-network provider may be your only option, particularly when you're traveling or facing a medical emergency. As medical costs continue to rise, every little bit of knowledge and preparation counts in keeping your healthcare costs affordable and your health concerns addressed. If you're ready to start shopping for a health insurance policy, you can peruse all of the options available to you right here at


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