Out-of-Network Care

Updated: 29 February 2024

What Does Out-of-Network Care Mean?

Out-of-network care refers to health and medical treatments an insured person receives from a healthcare facility that is not listed in their insurer's preferred provider network.

Insurers negotiate rates with the members of their preferred provider network. Those who operate outside that network regulate their own rates independently, and can charge much higher rates for the same procedures. As a result, the cost for out-of-network care might only be partially covered by the insurance.

Insuranceopedia Explains Out-of-Network Care

Policyholders might still get coverage for treatment from out-of-network healthcare facilities. They will get the same amount of coverage than they would from an in-network provider, but that amount may not reimburse them for the full costs. Any cost in excess of the rate negotiated with in-network providers will have to be paid out of pocket by the insured.

Some policies, however, such as many plans provided by health management organizations (HMOs), provide no coverage at all for out-of-network care.

Despite the higher costs, policyholders might opt for out-of-network care either out of necessity (such as getting emergency care from the nearest facility or getting care while out of town) or to get specialized care not provided within your insurer's network.

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