What Happens If You Go Out of Network?

Going out of network can mean paying more for health care, paying the entire bill yourself, or receiving special federal protections depending on why and where you received the care. PPO and some POS plans may provide routine out-of-network benefits at higher member cost, while HMO and EPO plans generally provide little or no routine out-of-network coverage. Emergency services and certain unexpected out-of-network services receive different treatment under federal surprise-billing protections. Before choosing an out-of-network provider voluntarily, check the exact plan’s network, deductible, coinsurance, allowed amount, balance-billing rules, referral requirements, and out-of-pocket protections.

Key Takeaways

An out-of-network provider does not have a contract with your health plan to provide services at negotiated network rates.
Routine out-of-network care usually costs more when the plan provides out-of-network benefits.
An HMO generally does not cover voluntary routine out-of-network care except when an applicable exception applies.
An EPO generally covers services only when you use network providers, except for emergencies and other applicable protections.
A PPO generally allows you to use out-of-network providers but at an additional cost.
POS plans can have network and referral rules that differ from PPOs, so the policy must be checked carefully.
Out-of-network deductibles and coinsurance can be higher than in-network cost sharing.
Some plans maintain separate in-network and out-of-network deductibles.
Your insurer may calculate out-of-network benefits from an allowed amount rather than the provider’s full billed charge.
An out-of-network provider may sometimes bill you for the difference between its charge and the plan’s allowed amount. This is called balance billing.
Federal law prohibits many surprise balance bills for most emergency services and certain out-of-network services received at in-network facilities.
Qualifying emergency services generally cannot require prior authorization merely because the provider or facility is out of network.
Protected emergency and certain facility-based services generally must use in-network cost-sharing treatment.
Ordinary voluntary out-of-network care generally does not receive the same federal surprise-billing protection.
The federal No Surprises Act generally does not protect routine non-emergency care obtained at an out-of-network facility.
Ground ambulance services generally are not covered by the federal No Surprises Act balance-billing protections, although state rules can provide additional protection.
Ordinary out-of-network spending generally does not count toward the standard Marketplace out-of-pocket maximum.
Amounts above the plan’s allowed amount generally do not count toward that standard out-of-pocket maximum either.
A referral and prior authorization are different requirements.
Always verify both the provider and facility network status before planned care.
When a bill appears to violate surprise-billing protections, you can contact the insurer, appeal when appropriate, and use federal or state complaint processes.

What Does Out of Network Mean?

A health insurance network is a group of doctors, hospitals, laboratories, pharmacies, facilities, and other providers that have contracted with the health plan.

An out-of-network provider is a provider that does not have that network contract with your plan.

Because no network agreement applies, the provider may charge different prices, and the health plan may pay less or nothing depending on the policy.

What Happens Depends on Your Plan Type

Plan Type	Routine Out-of-Network Care
HMO	Generally not covered except for emergencies or applicable approved exceptions.
EPO	Generally not covered outside the network except in emergencies and other protected situations.
PPO	Generally available, but the member usually pays more.
POS	Can provide additional provider flexibility, but referral, network, and out-of-network rules depend on the specific plan.

These are general characteristics rather than guarantees. The Summary of Benefits and Coverage and Evidence of Coverage determine how an individual plan treats a specific service.

Going Out of Network With an HMO

HMOs generally limit routine coverage to providers who work for or contract with the HMO.

If you voluntarily schedule non-emergency treatment with an out-of-network doctor without an applicable authorization or other exception, the plan may pay nothing.

You could therefore become responsible for the provider’s full charge rather than simply paying a higher coinsurance rate.

Do not assume you can simply pay a higher HMO copay: An HMO may provide no routine out-of-network benefit at all.

Going Out of Network With an EPO

An Exclusive Provider Organization also generally requires members to receive covered routine care from network providers.

If you voluntarily see an out-of-network specialist for non-emergency care, you may be responsible for the entire charge unless an applicable exception or federal protection applies.

An EPO can therefore offer direct access to in-network specialists while still providing much less out-of-network flexibility than a PPO.

Going Out of Network With a PPO

PPOs generally provide the greatest routine out-of-network flexibility among the common network types.

HealthCare.gov explains that PPO members can use providers outside the network without a referral for an additional cost.

That additional cost can include:

A larger deductible.
Higher coinsurance.
A larger copayment.
Balance-billing exposure where permitted.
Costs that do not count toward the standard in-network out-of-pocket maximum.
Additional paperwork or claim-submission responsibilities in some situations.

Out-of-Network Deductibles

Some plans that provide out-of-network benefits maintain a separate deductible for those services.

Illustrative Deductible Example

Assume a hypothetical PPO has a $2,000 in-network deductible and a $4,000 out-of-network deductible.

Reaching the $2,000 in-network deductible does not necessarily mean the separate $4,000 out-of-network deductible has also been satisfied.

Actual deductible structures vary by plan. The figures are hypothetical.

Out-of-Network Coinsurance

Out-of-network coinsurance is the percentage of the plan’s applicable allowed amount that you pay for covered care from a nonparticipating provider.

HealthCare.gov notes that out-of-network coinsurance usually costs more than in-network coinsurance.

Illustrative Coinsurance Example

Assume a covered out-of-network service has a plan allowed amount of $1,000 and your out-of-network coinsurance is 40% after the deductible.

Your coinsurance would be $400 based on the $1,000 allowed amount.

However, if the provider charges more than the allowed amount, you may face additional costs unless balance billing is prohibited. All figures are hypothetical.

What Is the Allowed Amount?

HealthCare.gov defines the allowed amount as the maximum amount a plan will pay for a covered health care service.

It may also be called an eligible expense, payment allowance, or negotiated rate depending on the context.

The allowed amount becomes especially important outside the network because the provider’s actual charge can exceed the amount the insurer recognizes when calculating benefits.

What Is Balance Billing?

Balance billing occurs when a provider bills you for the difference between its charge and the amount recognized or paid under the health plan.

Illustrative Balance-Billing Example

An out-of-network provider charges $1,500.

The plan recognizes an allowed amount of $1,000.

Your deductible and coinsurance may be calculated using the $1,000 amount rather than the $1,500 charge.

The remaining $500 can potentially become a balance bill when legally permitted. Federal or state surprise-billing protections can prohibit that result in protected situations. The example is hypothetical.

When the No Surprises Act Protects You

Federal No Surprises Act protections apply to many people enrolled in employer-sponsored or individual private health coverage.

Important protections generally cover:

Most emergency services from an out-of-network provider or facility.
Certain non-emergency services from out-of-network providers associated with a visit to an in-network hospital.
Certain services at an in-network hospital outpatient department.
Certain services at an in-network ambulatory surgical center.
Covered services provided by an out-of-network air ambulance provider.

When the federal protections apply, you generally cannot be required to pay higher out-of-network cost sharing merely because the provider was outside the network.

Out-of-Network Emergency Care

An emergency is fundamentally different from deliberately choosing an out-of-network physician for planned care.

For qualifying emergency services, applicable health plans generally must provide coverage without requiring prior authorization solely because the provider or facility is outside the network.

The member generally must be treated using in-network cost-sharing rules for services protected by federal law.

In an actual emergency: Do not delay necessary care solely to search for an in-network hospital. Emergency services receive special protections that ordinary voluntary out-of-network care does not.

An In-Network Hospital Can Still Have Out-of-Network Providers

One of the major reasons surprise-billing protections exist is that being admitted to an in-network facility does not guarantee every professional involved in your care has a network contract with your plan.

An in-network facility can involve services from professionals such as:

Anesthesiologists.
Radiologists.
Pathologists.
Assistant surgeons.
Other clinicians participating in your treatment.

Federal protections prohibit many unexpected out-of-network charges in these protected facility-based situations.

When the No Surprises Act May Not Protect You

Federal surprise-billing protections do not turn every out-of-network service into in-network care.

Protections generally do not apply in the same way when:

You voluntarily schedule routine non-emergency treatment with an out-of-network doctor’s office.
You intentionally choose an out-of-network facility for planned treatment.
The service would not have been covered even if it had been provided in-network.
You validly waive certain protections through a permitted notice-and-consent process.
The bill involves ground ambulance services and no additional state protection applies.
The insurance product itself falls outside the federal provisions applicable to ordinary comprehensive private health coverage.

Ground Ambulances Are an Important Exception

The federal No Surprises Act generally does not extend its balance-billing protections to ground ambulance services.

A ground ambulance may therefore be out of network even when the emergency room itself receives federal surprise-billing protection.

Some states provide additional protections, so the final result depends on where the service occurred and what coverage applies.

What Is Notice and Consent?

In certain non-emergency situations, an out-of-network provider can give a patient a specific notice explaining that the provider is outside the network and that choosing the provider may result in greater costs.

A valid notice-and-consent process can allow the patient to waive some federal balance-billing protections when federal rules permit that waiver.

Do not sign automatically: A notice-and-consent form can mean voluntarily giving up important protections against higher out-of-network bills. Read it carefully and ask whether an in-network provider is available.

Does Out-of-Network Spending Count Toward Your Out-of-Pocket Maximum?

Ordinary voluntary out-of-network spending generally does not count toward the standard Marketplace out-of-pocket maximum.

HealthCare.gov states that the out-of-pocket limit generally excludes:

Monthly premiums.
Services the plan does not cover.
Out-of-network care and services.
Amounts above the allowed amount that a provider may charge.

For 2026 Marketplace plans, the federal maximum for covered in-network cost sharing cannot exceed $10,600 for an individual or $21,200 for a family, although many plans use lower limits.

Protected surprise-billing services are different: When No Surprises Act protections apply, required cost sharing for the protected service generally must be treated using applicable in-network rules.

Referral vs. Prior Authorization

These terms are related to health plan administration, but they are not interchangeable.

Term	General Meaning
Referral	A written order from a primary care doctor for you to see a specialist or receive certain services.
Prior authorization	Approval from the health plan that may be required before a service, treatment, drug, or other item will be covered.

A referral to a specialist does not automatically mean an out-of-network provider is covered, and prior authorization does not necessarily guarantee payment if other coverage requirements are not satisfied.

What if No In-Network Provider Can Treat You?

Sometimes the required specialist, treatment, or facility is not reasonably available inside the plan’s network.

In that situation, contact the health plan before scheduling non-emergency treatment and ask whether it can authorize an out-of-network provider under an exception, network-gap arrangement, or other applicable process.

Terminology and rights vary by plan and state, so obtain the authorization or explanation in writing when practical.

Do Not Assume “Accepts My Insurance” Means In Network

A provider saying that it “accepts” an insurance company does not necessarily confirm that it participates in your exact network.

Before planned treatment:

Identify your exact plan and network name.
Check the insurer’s provider directory.
Check the provider’s specific practice location.
Verify the hospital or facility separately.
Confirm with the provider when practical.
Ask the insurer directly when expensive treatment is planned.

Check Both the Doctor and the Facility

Network status can differ between the physician and the place where treatment occurs.

An in-network doctor might perform a procedure at a facility that is outside your network, or an in-network facility might use some out-of-network professionals.

Federal protections address many unexpected facility-based situations, but deliberately choosing an out-of-network facility for scheduled treatment can still expose you to significantly greater costs.

What if You Get an Out-of-Network Bill?

Do not assume the amount on the first bill is automatically correct.

Review the insurer’s Explanation of Benefits.
Confirm whether the provider and facility were in network.
Determine whether the service was emergency or non-emergency care.
Check whether the No Surprises Act applies.
Check whether state surprise-billing protections apply.
Compare the provider bill with the insurer’s allowed amount and cost-sharing calculation.
Contact the insurer if the claim appears incorrectly processed.
Contact the provider if it appears to be billing more than permitted.
Use the plan’s appeal process when appropriate.
Submit a complaint to the appropriate federal or state authority when necessary.

Can You Appeal an Out-of-Network Claim?

Potentially, yes.

An appeal may be worth considering when you believe:

The provider was incorrectly listed as out of network.
The service should have received emergency protections.
A valid network exception had been authorized.
The insurer incorrectly applied the deductible or coinsurance.
The service was denied for a reason you believe contradicts the policy.
The claim should have received protections under applicable federal or state law.

Follow the appeal instructions provided by the plan and keep copies of medical records, authorizations, provider-directory information, bills, and correspondence.

When Going Out of Network May Still Make Sense

Higher cost does not automatically mean an out-of-network provider is never worth considering.

A patient might consider out-of-network treatment when:

A highly specialized physician is unavailable in the network.
The patient has an established relationship with a particular specialist.
Continuity of complex treatment is important.
The plan approves a network-gap exception.
The patient understands the additional financial exposure and considers it acceptable.

The key is to determine the expected financial responsibility before planned care whenever possible.

Common Out-of-Network Mistakes

Assuming Every Plan Covers Out-of-Network Care

HMOs and EPOs commonly provide no routine out-of-network benefit.

Assuming a PPO Makes Out-of-Network Care Cheap

PPO coverage can reduce the financial exposure, but separate deductibles, higher coinsurance, and balance billing can still make care expensive.

Checking Only the Doctor

The facility, laboratory, imaging center, and other professionals can have different network status.

Confusing “Accepts Insurance” With “In Network”

The provider must participate in your exact plan network, not simply work with the same insurance company.

Assuming the Out-of-Pocket Maximum Protects Every Dollar

Ordinary out-of-network spending and amounts above the plan’s allowed amount generally do not count toward the standard Marketplace out-of-pocket maximum.

Assuming No Surprises Protections Apply Everywhere

The federal law protects important categories of unexpected bills but does not convert ordinary voluntary out-of-network treatment into in-network care.

Ignoring Ground Ambulance Exposure

Federal surprise-billing protections generally do not cover ground ambulance services, although state protections can differ.

Signing a Notice-and-Consent Form Without Reading It

A permitted waiver can mean voluntarily giving up certain federal billing protections.

Before Going Out of Network: Checklist

Identify your exact plan type and network.
Confirm whether routine out-of-network care is covered.
Check the provider’s network status.
Check the facility’s network status.
Check laboratories and imaging providers when relevant.
Review the out-of-network deductible.
Review out-of-network coinsurance or copayments.
Ask how the plan determines its allowed amount.
Ask whether the provider can balance bill you.
Determine what out-of-network expenses count toward any deductible or spending limit.
Check whether a referral is required.
Check whether prior authorization is required.
Ask whether a network-gap exception is available.
Ask the provider for an estimated charge.
Ask the insurer for an estimated benefit when practical.
Review any notice-and-consent form carefully.
Keep written documentation of authorizations and network confirmations.

Frequently Asked Questions

What happens if I see an out-of-network doctor?

You may pay higher deductibles or coinsurance, face balance billing, or receive no plan payment at all depending on your plan. Emergency and certain unexpected facility-based services receive additional federal protections.

Will an HMO pay for an out-of-network doctor?

Generally not for voluntary routine care. Emergency services and applicable approved or legally protected situations can be treated differently.

Does an EPO cover out-of-network care?

EPO plans generally cover services only when you use network providers, except for emergencies and other applicable protections or exceptions.

Does a PPO cover out-of-network care?

Generally, yes. PPOs commonly allow members to use out-of-network providers at an additional cost, subject to the plan’s deductible, coinsurance, allowed-amount, and other rules.

What is balance billing?

Balance billing occurs when a provider bills you for the difference between its charge and the amount recognized or paid under the health plan. Federal and state law prohibit balance billing in certain protected situations.

Do out-of-network expenses count toward my out-of-pocket maximum?

Ordinary out-of-network care generally does not count toward the standard Marketplace out-of-pocket maximum. Protected services under federal surprise-billing rules receive different cost-sharing treatment.

What happens if I have an emergency at an out-of-network hospital?

Qualifying emergency services generally must be covered without out-of-network prior authorization, and applicable federal rules generally limit your cost sharing to in-network treatment for protected services.

Does the No Surprises Act cover ground ambulances?

Generally, no. Ground ambulance bills are generally outside the federal No Surprises Act balance-billing protections, although a state may provide additional rights.

Can I appeal an out-of-network bill?

You may be able to appeal how the insurer processed the claim, particularly when you believe emergency protections, a network authorization, coverage terms, or applicable federal or state protections were applied incorrectly.

Can an in-network hospital use out-of-network doctors?

Yes. An in-network hospital can involve out-of-network anesthesiologists, radiologists, pathologists, or other professionals. Federal law protects consumers from many surprise bills arising in these circumstances.

What if my plan has no in-network specialist for my condition?

Contact the health plan before non-emergency treatment and ask whether it can authorize an out-of-network provider because the network cannot reasonably provide the required care. Available processes and rights depend on the plan and applicable law.

How can I tell if a doctor is really in network?

Check the insurer’s provider directory using the exact plan and network name, confirm the provider’s specific practice location, and verify directly with the insurer when significant treatment is planned.

The Bottom Line

Going out of network can dramatically change what your health insurance pays and what you owe. With an HMO or EPO, voluntary routine out-of-network care may receive no coverage at all. With a PPO, the plan may contribute toward the service, but a separate deductible, higher coinsurance, and possible balance billing can substantially increase your cost.

The allowed amount is particularly important. Even when your plan covers a percentage of out-of-network care, the insurer may calculate its benefit from an allowed amount that is lower than the provider’s actual charge. When legally permitted, the provider can potentially bill you for part of that difference.

Emergency and certain unexpected facility-based services receive important federal protections. Under the No Surprises Act, qualifying out-of-network emergency care and certain out-of-network services received at in-network facilities generally cannot result in higher out-of-network cost sharing or prohibited surprise balance bills.

Those protections have limits. Voluntarily using an out-of-network doctor’s office or out-of-network facility for routine non-emergency treatment generally does not receive the same protection, and federal rules generally do not cover ground ambulance balance bills.

Before planned care, verify the exact doctor, facility, network, deductible, coinsurance, allowed-amount calculation, authorization requirements, and balance-billing exposure. If you receive an unexpected out-of-network bill, review the Explanation of Benefits before paying and determine whether federal or state protections apply.

Sources

HealthCare.gov, Health Insurance Plan & Network Types: HMOs, PPOs, and More, accessed August 2026.
HealthCare.gov, Allowed Amount Glossary, accessed August 2026.
HealthCare.gov, Balance Billing Glossary, accessed August 2026.
HealthCare.gov, Out-of-Network Coinsurance Glossary, accessed August 2026.
HealthCare.gov, Out-of-Network Copayment Glossary, accessed August 2026.
HealthCare.gov, Out-of-Pocket Maximum/Limit Glossary, accessed August 2026.
HealthCare.gov, Referral Glossary, accessed August 2026.
HealthCare.gov, Prior Authorization and Preauthorization Glossaries, accessed August 2026.
HealthCare.gov, Getting Emergency Care, accessed August 2026.
Centers for Medicare & Medicaid Services, Know Your Medical Bill of Rights, updated August 25, 2026.
Centers for Medicare & Medicaid Services, No Surprises Act Consumer Protections, accessed August 2026.
Centers for Medicare & Medicaid Services, Action Plan for Bills From an Out-of-Network Provider, updated August 2026.
Centers for Medicare & Medicaid Services, Health Insurance Terms You Should Know, updated August 2026.