What Is Out-of-Network
Out-of-network means a healthcare provider or facility does not have a contract with your insurance plan. When you use an out-of-network provider, you typically pay higher costs, receive reduced coverage, or may not be covered at all. This distinction matters significantly if you receive Medicaid, qualify for marketplace insurance through government subsidies, or use health benefits tied to SNAP, TANF, or WIC eligibility.
Out-of-Network and Government Benefits
Government assistance programs handle out-of-network providers differently depending on the program:
- Medicaid: Coverage varies by state. Some state Medicaid programs cover out-of-network emergency services but require prior authorization for non-emergency care. You typically pay no copay for in-network providers but may face balance billing from out-of-network providers.
- SNAP and TANF: These cash assistance programs don't directly cover healthcare, but recipients often qualify for Medicaid. Check your state's Medicaid rules to understand out-of-network coverage limits.
- WIC: WIC nutrition services only work with approved WIC vendors. Using a non-WIC vendor means you pay full price and cannot use WIC benefits.
- Marketplace insurance: If you receive federal subsidies (Advanced Premium Tax Credits) through Healthcare.gov, your plan documents specify which providers are in-network. Plans typically cover 50 to 70 percent of out-of-network costs after you meet your out-of-pocket maximum.
Cost Impact and Your Responsibility
Using an out-of-network provider can cost significantly more. For example, if your in-network visit copay is $25 but you see an out-of-network provider charging $150, you might pay the full $150 plus a percentage of additional charges. This is called "balance billing," and some states limit it for Medicaid beneficiaries, but protections vary widely.
Before scheduling an appointment, always ask the provider's office if they accept your insurance. Request confirmation in writing. If you need emergency care, you cannot choose the hospital, so most plans cover emergency out-of-network services at in-network rates.
How to Check Your Network
- Call your insurance company and ask for the provider directory or access it online through your plan's website.
- Search the Centers for Medicare and Medicaid Services (CMS) provider locator if you have Medicaid.
- Ask your doctor's office directly whether they participate in your specific plan (not just the insurance company).
- If you already received care and are unsure, check your Explanation of Benefits (EOB) document, which shows in-network vs. out-of-network charges.
Common Questions
What happens if I accidentally use an out-of-network provider? Contact your insurance company immediately and request an exception or ask about covering the claim as in-network if it was a legitimate mistake. Some plans allow this for first-time situations.
Are out-of-network costs deductible on my taxes? Medical expenses (both in and out-of-network) are only deductible if you itemize deductions and expenses exceed 7.5 percent of your adjusted gross income. Most people receiving government assistance do not meet this threshold.
Can my state's Medicaid program force me to use in-network providers? Medicaid plans often require in-network use for non-emergency care. However, if no in-network provider exists within 30 miles, federal rules may require covering an out-of-network provider at in-network rates. Contact your state Medicaid office for specifics.