Out-of-network
Updated September 30, 2026
Definition
Describes a provider or facility that doesn't have a contract with your health plan. Out-of-network care usually costs you more, and the provider may bill you above your plan's allowed amount.
Out-of-network means a provider or facility doesn't have a contract with your health plan. Your plan hasn't agreed on prices with them, so your share is usually higher. The provider may also send you a balance bill for the gap between its charge and your plan's allowed amount.
For example, say an out-of-network provider charges $1,000 and your plan allows $400. Your plan pays 60%, or $240, and your 40% share is $160. The provider may also bill you the $600 gap, so you could owe $760 in all.
Federal law limits this in many cases, like most emergency care. Before you pay an out-of-network bill, see does the No Surprises Act apply to my bill.
Related terms
Guides that use this term
- GuideOut-of-network anesthesia at an in-network hospitalGot an out-of-network anesthesia bill after care at an in-network hospital? Federal law usually limits you to your in-network share. Here's what to do.
- GuideDoes the No Surprises Act apply to my bill?The No Surprises Act limits many surprise out-of-network bills. See when it applies, what it doesn't cover, and what to do if you get a surprise bill.
- GuideWhy is my medical bill higher than my EOB?Your bill asks for more than your EOB says you owe? See the usual reasons, a worked example, and the steps to get a corrected bill before you pay.
Sources
- Health insurance terms you should know, Centers for Medicare & Medicaid Services. Accessed September 30, 2026.
- Out-of-network coinsurance (glossary), HealthCare.gov. Accessed September 30, 2026.
- Balance billing (glossary), HealthCare.gov. Accessed September 30, 2026.
This is general information, not legal or medical advice. Rules can depend on your plan and your state. Romi Care isn't an insurer, law firm, collection agency, or government program.