Out-of-Network Care

What Does Out-of-Network Care Mean?

Out-of-network care refers to medical treatments or services received from healthcare providers or facilities that are not part of an insurer’s preferred provider network.

Insurers negotiate discounted rates with providers within their network. However, out-of-network providers set their rates independently, often charging significantly higher fees for the same procedures. Consequently, insurance may only partially cover the cost of out-of-network care, leaving the insured responsible for a larger portion of the expense.

Insuranceopedia Explains Out-of-Network Care

Policyholders may still receive coverage for treatment from out-of-network healthcare providers, but the reimbursement amount is typically based on the rates negotiated with in-network providers. This means the coverage may not fully offset the higher costs of out-of-network care, and the policyholder must pay any difference out of pocket.

However, some policies—such as many plans offered by health management organizations (HMOs)—do not cover out-of-network care at all.

Despite the higher costs, policyholders may choose out-of-network care for various reasons, such as necessity (e.g., emergency care at the nearest facility or care required while traveling) or access to specialized services unavailable within the insurer’s network.