In-network vs out-of-network comes down to a contract. In-network providers agreed to discounted prices with your plan, so you pay less. Out-of-network providers have no deal, so your plan may pay little or nothing, and the provider can bill you the difference. However, the No Surprises Act blocks many of those bills, including most emergency care.
- In-network care uses the price your plan negotiated, while out-of-network care often costs far more or isn't covered at all.
- HMO and EPO plans generally cover out-of-network care only in an emergency, but PPO plans cover some of it at a higher cost.
- Balance billing means a provider bills you the gap between its charge and your plan's allowed amount.
- The No Surprises Act protects you in emergencies, from many out-of-network doctors at in-network hospitals and for air ambulance rides.
- Ground ambulance rides are not covered by the federal surprise-billing protections.
In-network vs out-of-network: what is the difference?
First, every plan builds a network of doctors, hospitals, labs and pharmacies. Those providers signed a contract that sets a lower price for plan members. So when you stay in network, you get that price and your plan pays its full share.
- Discounted, pre-set prices
- Your normal copays and coinsurance
- Counts toward your yearly cap
- No balance bill
- Full billed price may apply
- Higher cost sharing, or no coverage
- Often outside your yearly cap
- Balance bills are possible
Two terms that explain the bill
The allowed amount is the most your plan will pay for a covered service. Balance billing happens when a provider bills you for the difference between its charge and that allowed amount. For example, HealthCare.gov notes that if a provider charges $100 and the allowed amount is $70, the provider may bill you $30. In-network providers can't do that, because their contract bars it.
In-network vs out-of-network costs: an example
Real numbers show the in-network vs out-of-network gap best. Say an MRI center charges $2,000. Your plan's allowed amount is $800, and you already met your deductible. These figures are for illustration only, not a quote.
| Where you go | What you pay | Why |
|---|---|---|
| In network | $160 | 20% of the $800 allowed amount |
| Out of network on a PPO | $1,520 | 40% of $800, plus a $1,200 balance bill |
| Out of network on an HMO or EPO | $2,000 | No coverage, so you pay the full charge |
So the same scan can cost nearly ten times more outside the network. Also, out-of-network spending usually doesn't count toward your in-network cap. Learn how the yearly spending cap works and what sits outside it.
Out-of-network coverage by plan type
Your plan type decides whether out-of-network care gets any coverage. Here is how HealthCare.gov describes the four main types.
No out-of-network coverage, except in an emergency.
Care is covered only in network, except in an emergency.
You pay less in network, and you need a referral to see a specialist.
You can go outside the network without a referral, but at an extra cost.
If you have a must-keep doctor outside a carrier's network, a PPO may be worth a higher premium. Compare HMO and PPO rules side by side, or read how EPO and POS plans handle referrals. Our guide to every plan type covers all seven.
A licensed Vivna agent can confirm which plans include your doctors and hospital, across 50+ carriers, at no cost to you.
Surprise bills and the No Surprises Act
A surprise bill happens when you get out-of-network care you didn't choose. For example, you have surgery at an in-network hospital, but the anesthesiologist isn't in your network. Since January 1, 2022, the No Surprises Act has blocked many of these bills.
Where the law protects you
- Emergency room care, even at an out-of-network hospital
- Many out-of-network doctors at an in-network hospital or surgery center
- Air ambulance rides
In those cases, you only pay your in-network share. Also, your plan must count what you pay toward your in-network deductible and out-of-pocket limit.
Where it doesn't reach
- Ground ambulance rides, unless your state has its own law
- An out-of-network doctor you chose, after you signed a valid consent form
- Services your plan doesn't cover at all
The consent form rule
Some out-of-network providers can ask you to sign away your protections for planned care. However, CMS says emergency, anesthesiology, pathology, radiology and neonatology providers can't ask. Assistant surgeons, hospitalists and intensivists can't ask either. Signing is always your choice.
Never sign a consent form you don't understand, especially on the day of a procedure. If a provider breaks the rules, you can file a complaint with the No Surprises Help Desk at 1-800-985-3059. Read more about how medical bills and claims move.
Other in-network vs out-of-network rights
In addition, the same law added a few quieter protections. They help when the network changes or a directory is wrong.
Wrong directory listings
Plans must check their provider directories at least every 90 days. So if you rely on a listing that turns out to be wrong, your cost sharing stays at in-network levels. Take a screenshot of the listing before your visit.
When a doctor leaves the network
Some patients, such as those who are pregnant or in active treatment, may keep seeing that doctor for up to 90 days at in-network rates. CMS notes the rules for this protection are still pending, so ask your plan. Here is what to do when your doctor drops out.
If you pay without insurance
Uninsured or self-pay patients can ask for a good faith estimate. If the final bill comes in at least $400 above that estimate, you may be able to dispute it.
In-network vs out-of-network in common situations
Real life rarely follows the plan brochure. So here is what to do in the situations our agents hear about most.
| Situation | What to do |
|---|---|
| A medical emergency | Go to the nearest ER, since federal law protects you |
| Planned surgery | Ask who the anesthesiologist and lab will be |
| No in-network specialist nearby | Ask your plan for a network exception first |
| Travel within the U.S. | Use in-network urgent care or telehealth when you can |
| You want a doctor outside the network | Get a written estimate, because no protection applies |
If you split time between two states
Many plans build networks by state or region. As a result, a plan that works at home may have few doctors where you spend the winter. Before you enroll, ask whether the carrier's network reaches both areas. Also, remember that emergency care is protected anywhere in the country.
How to stay in network and avoid out-of-network costs
Most out-of-network bills start with one missed check. So build these steps into every planned visit.
- Search the carrier directory
Look up each doctor by name and ZIP code. Then note the exact plan name it lists.
- Call the office
Ask if they take your exact plan, not just the carrier, because carriers sell several networks.
- Check the whole team
Before surgery, also ask about the lab, imaging center, anesthesiologist and facility.
- Get it in writing
Request a cost estimate, and keep notes with names and dates.
When you call a doctor's office, read them the plan name exactly as it appears on your ID card. We often see offices say yes to the carrier but no to the specific network. Also, recheck your doctors every fall, because networks change at renewal.
Use our carrier network search links to start, and see five ways to confirm a doctor takes your plan. Also, learn how network size changes what you pay. When you are ready, compare ACA and private medical plans or call 888-730-6001.
In-network vs out-of-network: FAQs
Why does out-of-network care cost so much more?
You lose the discount your plan negotiated, so the provider can charge its full price. Also, your plan may pay a smaller share, or nothing at all on an HMO or EPO. On top of that, the provider can balance bill you for the gap between its charge and the allowed amount, unless federal or state law blocks it.
Is emergency care covered out of network?
Yes. Under the No Surprises Act, plans must cover emergency care at an out-of-network hospital without prior approval. You pay only your in-network share, and the provider can't balance bill you. Also, what you pay counts toward your in-network deductible. Just remember that ground ambulance rides fall outside these federal protections.
Do out-of-network costs count toward my out-of-pocket maximum?
Usually not. Most plans track out-of-network spending separately, and some PPOs have a separate, higher cap or none at all. Balance bills never count. However, care the No Surprises Act protects, such as emergency care, does count toward your in-network deductible and limit.
Does an HMO cover out-of-network doctors?
Generally, no. HealthCare.gov says HMOs usually won't cover out-of-network care except in an emergency. EPOs work the same way. If you need a doctor outside the network, ask your plan about an exception before the visit. Otherwise, a PPO plan offers some coverage outside the network for an extra cost.
What should I do if I get a surprise bill?
First, compare the bill to your Explanation of Benefits. Next, call your plan and the provider to ask why it was billed out of network. If you think the No Surprises Act applies, call the help desk at 1-800-985-3059. You can also appeal a denied claim step by step.
Can a licensed agent check if my doctors are in network?
Yes. A licensed agent can check your doctors, hospital and pharmacy against several plans before you enroll. Vivna's agents compare plans from 50+ carriers, such as UnitedHealthcare, Ambetter and Oscar, at no cost to you. Call 888-730-6001 Monday through Friday, 9am to 6pm.
Vivna's licensed agents compare plans from 50+ carriers. Call Monday through Friday, 9am to 6pm.
Sources
- CMS: Know your medical bill rights when using insurance
- HealthCare.gov: Balance billing
- CMS: No Surprises Act overview of key consumer protections
- HealthCare.gov: Health insurance plan and network types
- CMS: Your rights and protections against surprise medical bills
- CMS: Medical bill rights and the No Surprises Help Desk
Vivna Insurance is a licensed, independent health insurance agency (NPN 19168641). We are not affiliated with HealthCare.gov or any government agency. Plan availability, networks and benefits vary by state and change over time.
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