Out-of-network

What It Means

Out-of-network describes a doctor, hospital or other provider that doesn't have a contract with your health planHealth insuranceA plan you pay a premium for that covers part of your medical costs, while you pay your own share through a deductible, copays and coinsurance. See more. If the plan covers out-of-network care at all, HealthCare.gov says you'll usually pay more for it, and the provider may bill you for the gap between its charge and the amount your plan allows, which is called balance billing. Out-of-network care doesn't count toward your out-of-pocket maximumOut-of-pocket maximumThe most you pay in a plan year for covered in-network care through deductibles, copays and coinsurance, after which the plan pays covered benefits in full. See more.

How People Say It

• "The anesthesiologist was out-of-network and nobody told us."
• "Our PPO pays something for out-of-network, but not much."
• "Can you check if that urgent care is out of network?"

The Breakdown

What the rules say. Your plan decides whether it pays anything for out-of-network care, and HealthCare.gov's plan types page shows the usual pattern:

When a plan does cover it, your share is set by the plan's out-of-network copayCopayA fixed dollar amount, such as $20, that you pay for a covered health care service under your health insurance plan. See more or coinsuranceCoinsuranceYour share of the cost of a covered health care service, set as a percentage such as 20%, that you pay after meeting your deductible. See more, which HealthCare.gov's glossary lists as terms of their own, and the provider may balance bill you for charges above the allowed amount.

The No Surprises Act. CMS says the law protects people in group and individual health plans from surprise bills for most emergency services, for some non-emergency care from out-of-network providers at an in-networkIn-networkDescribes a doctor, hospital or other provider that has a contract with your health plan, so you usually pay less for covered care than you would outside the network. See more hospital, hospital outpatient department, critical access hospital or ambulatory surgical center, and for out-of-network air ambulance services. In those cases your cost-sharing can't be higher than it would be in network. CMS adds that the protections generally don't apply to non-emergency care at an out-of-network facility.

Who it applies to. Anyone with a health plan that has a network. The No Surprises Act protections cover people in group and individual health plans.

Documents to keep

• The bill from the provider
• The explanation of benefitsExplanation of benefitsA statement from your health plan, not a bill, that shows what a provider charged for a visit, what the plan paid and what you may owe. See more from your plan for the same visit
• Notes of calls, with the date and the name of the person you spoke to

Official source. HealthCare.gov's glossary and CMS's No Surprises Act pages, checked October 2026.

Good to Know

Before planned care at a hospital or surgery center, ask whether everyone involved is in your network, including the anesthesiologist, radiologist and lab, since CMS's protections cover some care at in-network facilities and generally not care at out-of-network ones. If a bill looks like a surprise bill, compare it with your explanation of benefits before paying, then call your plan, and read CMS's No Surprises pages for what the law covers.

Related Terms and Categories

• In-network

  Describes a doctor, hospital or other provider that has a contract with your health plan, so you usually pay less for covered care than you would outside the network.

• Explanation of benefits

  A statement from your health plan, not a bill, that shows what a provider charged for a visit, what the plan paid and what you may owe.

• Out-of-pocket maximum

  The most you pay in a plan year for covered in-network care through deductibles, copays and coinsurance, after which the plan pays covered benefits in full.

• Coinsurance

  Your share of the cost of a covered health care service, set as a percentage such as 20%, that you pay after meeting your deductible.

• Health insurance

  A plan you pay a premium for that covers part of your medical costs, while you pay your own share through a deductible, copays and coinsurance.

• Medical debt

  Money owed for health care, such as hospital, doctor, lab or ambulance bills; unpaid bills can go to collections and, in some cases, onto credit reports.

Planning and life admin