What does out-of-network mean?

Insurance carriers work with some healthcare providers to provide healthcare services (known as in-network providers). An out-of-network provider is a healthcare provider who isn't within a carrier’s network. They are sometimes called non-preferred or non-participating providers.

What happens if I visit an out-of-network provider?

Your insurance carrier doesn’t have negotiated and predetermined rates with out-of-network providers. 

If you visit an out-of-network provider you’ll always end up spending more money. You’ll either:

• Receive less coverage: Your carrier will cover a smaller percentage of the cost. You’ll end up paying more of the cost on your own. 

• Receive no coverage: Your carrier won’t cover any of the cost. You’ll end up paying for the entire cost. This amount won’t count towards any deductibles or out-of-pocket maximums.

• Risk being balanced-billed: This happens when your provider bills you for an amount that is more than what your insurance plan will cover. For out-of-network claims, your plan will pay up to the usual and customary rate (UCR). Your carrier won't cover charges beyond this rate. These additional expenses won't go towards your annual out-of-network deductible and out-of-pocket maximums.

Example: Your plan offers some coverage for out-of-network providers. You visit an out-of-network dentist. The dentist charges you more than the usual and customary rate. Your carrier won’t cover the extra charges, and you end up having to spend more money out-of-pocket.

Tip: Read about how do I find an in-network provider.

How do I know if my plan offers any coverage for out-of-network providers?

Your Full Coverage Booklet provides details on your out-of-network coverage, if any. 

Note: Your plan will offer some coverage if you visit an out-of-network provider for emergency services.