In-network vs out-of-network describes whether a doctor, hospital or pharmacy has a contract with your health plan. In-network providers agreed to discounted rates, so you pay less and your costs count toward your out-of-pocket maximum. Out-of-network providers have no contract, so many plans pay little or nothing and you may be billed the difference.
Updated October 2026 for the 2027 plan year
Key facts (2027 plan year)
- A plan’s network is “the facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services” (HealthCare.gov).
- HMO and EPO plans generally don’t cover out-of-network care except in an emergency; PPO plans do, at a higher cost (HealthCare.gov plan types).
- For 2027, the out-of-pocket maximum for ACA plans is $12,000 for one person and $24,000 for a family, and out-of-network costs don’t count toward it (HealthCare.gov; CMS 2027 guidance).
- Since January 1, 2022, the No Surprises Act bans surprise out-of-network bills for most emergency care, for many non-emergency services at in-network hospitals and surgery centers, and for air ambulances (CMS).
- Ground ambulance rides are generally not covered by the No Surprises Act’s billing protections, though some states have their own rules (CMS).
- If you rely on a wrong provider directory listing and see an out-of-network provider, your plan must limit your cost-sharing to in-network amounts (CMS No Surprises Act training).
- What does in-network vs out-of-network mean?
- Why does in-network vs out-of-network change what you pay?
- Which plan types cover out-of-network care?
- How do I check if my doctor is in network before I enroll?
- What is balance billing, and when does the No Surprises Act protect you?
- What if the directory was wrong or my doctor leaves the network?
- What is network adequacy, and does network size matter?
- When is out-of-network coverage worth paying for?
- How Honesty checks networks for you
- Frequently asked questions
What does in-network vs out-of-network mean?
In-network means a provider signed a contract with your insurance company. Out-of-network means they didn’t. That one contract decides the price you pay, whether the visit counts toward your limits and whether you can be billed extra.
When a doctor joins a network, they agree to accept the plan’s negotiated rate, called the allowed amount, as payment in full. You pay your share, such as a copay or coinsurance, and the plan pays the rest.
An out-of-network provider never agreed to that rate and can charge full price. Hospitals, labs and pharmacies each have their own status, so a hospital can be in network while a specialist there is not. Our health insurance terms glossary defines the jargon.
Why does in-network vs out-of-network change what you pay?
Out-of-network care usually costs more for four reasons: a higher share of the bill, a separate deductible, no out-of-pocket cap, and balance billing.
1. A bigger share of the bill
HealthCare.gov lists separate in-network coinsurance and out-of-network coinsurance, and the out-of-network share is usually higher (see what coinsurance is).
2. A separate deductible
Many PPOs have one deductible in network and a second, larger one out of network.
3. No out-of-pocket maximum
For 2027 the out-of-pocket maximum can be no more than $12,000 for one person or $24,000 for a family, and HealthCare.gov says out-of-network costs don’t count toward it. Our guide to the deductible vs out-of-pocket maximum shows how the cap protects you.
4. Balance billing
Because out-of-network providers didn’t agree to the allowed amount, they can bill you the difference between their charge and what your plan paid. HealthCare.gov notes that a preferred (in-network) provider may not balance bill you for covered services.
| Cost feature | In-network | Out-of-network |
|---|---|---|
| Price basis | Plan’s negotiated allowed amount | Provider’s full charge |
| Your share | Copay or in-network coinsurance | Higher coinsurance, or the full bill on HMO/EPO plans |
| Deductible | In-network deductible | Often a separate, larger deductible |
| Counts toward 2027 out-of-pocket maximum | Yes | No |
| Balance billing allowed? | No, for covered services | Yes, unless the No Surprises Act or state law applies |
| Preventive care at no cost | Yes, on ACA plans | Generally no |
Which plan types cover out-of-network care?
PPO and POS plans cover some out-of-network care at a higher cost. HMO and EPO plans generally cover nothing out of network except emergencies, so on those plans the network is the plan.
| Plan type | Out-of-network care covered? | Referral to see a specialist? | Best fit |
|---|---|---|---|
| HMO | No, except emergencies | Often yes | Your doctors are all in one network and you want lower premiums |
| EPO | No, except emergencies | Usually no | You want specialist access without referrals inside one network |
| PPO | Yes, at higher cost | No | You see a provider who is out of network or travel often |
| POS | Yes, at higher cost | Yes | You want a primary doctor to coordinate care, with some flexibility |
Go deeper with HMO vs PPO vs EPO vs POS and how to choose a health plan.
Tell Honesty.AI who you see and what you take. It checks networks and drug lists before you pick a plan.
How do I check if my doctor is in network before I enroll?
Check every doctor, hospital and prescription against the exact plan name before you enroll, then confirm by phone. Networks differ between plans from the same insurer, so “they take that insurance” is not enough.
- List your care. Write down every doctor, specialist, therapist, hospital, lab and pharmacy you use, plus each prescription and dose.
- Use the Marketplace filter. When you preview plans on HealthCare.gov, add your doctors and drugs so the tool shows which plans include them. State exchanges have similar tools.
- Search the insurer’s directory by plan name. Open the carrier’s provider directory and pick the specific network for that plan. One insurer can sell several networks in the same county.
- Call the office. Ask, “Are you in network for [exact plan and network name] for 2027, and are you accepting new patients?”
- Check the hospital and the people inside it. If you plan surgery or a delivery, ask whether the surgeon, anesthesia group and hospital are all in network.
- Read the Summary of Benefits and Coverage. Every plan must give you a Summary of Benefits and Coverage. It shows in-network vs out-of-network costs side by side, and whether out-of-network care is covered at all.
Tip: Save a screenshot of each directory listing with the date. If the listing turns out to be wrong, that record helps you use the No Surprises Act directory protection explained below.
Next, see how to shop for health insurance and how to compare health insurance plans.
What is balance billing, and when does the No Surprises Act protect you?
Balance billing is when a provider bills you the difference between their charge and your plan’s allowed amount. Since January 1, 2022, the No Surprises Act bans these bills where you usually can’t choose your provider.
According to the Centers for Medicare & Medicaid Services (CMS), the No Surprises Act protects you from unexpected out-of-network bills for:
- Emergency services. CMS says emergency services must be treated on an in-network basis, wherever you get them, with no prior authorization requirement (CMS overview).
- Non-emergency care at in-network facilities. In most cases this covers out-of-network providers at in-network hospitals, hospital outpatient departments and ambulatory surgical centers.
- Air ambulance services.
In these cases, your coinsurance and deductible can’t be higher than they would be in network, and they must be based on in-network rates.
The consent form exception
For some scheduled, non-emergency care, an out-of-network provider at an in-network facility may ask you to sign a notice and consent form that gives up your protections. CMS says you aren’t required to sign it, and shouldn’t sign it if you didn’t have a choice of provider. CMS also says out-of-network charges for ancillary care, such as an anesthesiologist or assistant surgeon at an in-network facility, are banned in all circumstances.
What the law doesn’t cover
- Ground ambulances are generally not protected, unless your state has its own law.
- Short-term plans, fixed indemnity plans and health care sharing ministries are not subject to these protections, CMS says. That is one more reason to read our short-term health insurance guide before buying one.
- Care you choose from an out-of-network specialist at their own office is not a “surprise” bill.
Medicare, Medicaid, TRICARE and VA care have their own protections. To report a bill that breaks these rules, see CMS’s medical bill rights page.
What if the directory was wrong or my doctor leaves the network?
The No Surprises Act protects you in both cases. If you relied on a wrong directory listing, you pay in-network cost-sharing. If your doctor leaves mid-treatment, you may be able to keep seeing them at in-network terms for up to 90 days.
Wrong provider directory
Per CMS No Surprises Act training material, if you rely on incorrect directory information and get care from an out-of-network provider, your plan must limit your cost-sharing to in-network terms and apply your deductible and out-of-pocket maximum as if the provider were in network. The provider can’t bill you more than in-network cost-sharing, and must refund any extra you paid, plus interest.
Doctor leaves the network
If your provider’s contract ends while you are a “continuing care patient,” your plan must notify you and let you keep the same benefits until the earlier of 90 days from its notice or the end of your continuing care. CMS defines continuing care patients as people who are:
- being treated for a serious and complex condition,
- receiving inpatient or institutional care,
- scheduled for nonelective surgery, including post-op care,
- pregnant and being treated for the pregnancy, or
- terminally ill and being treated for that illness.
After that, mid-year plan changes usually require a Special Enrollment Period; a doctor leaving the network is not, by itself, a standard qualifying event, so plan to re-check networks every fall during Open Enrollment.
What is network adequacy, and does network size matter?
Network adequacy means a plan has enough providers for members to get care without unreasonable delay. A plan can meet federal minimums and still leave out the doctor you need.
Under 45 CFR 156.230, Marketplace plans must keep networks “sufficient in number and types of providers,” including mental health and substance use disorder providers. In HealthCare.gov states, issuers must meet federal time-and-distance standards (since plan years starting in 2023) and appointment wait-time standards (since 2025), unless the state runs its own review.
A narrow network can mean lower premiums; a broad one, more choice. The real test: are your doctors, nearest hospital and pharmacy in it? Judging networks is part of finding the best health insurance company for your ZIP code.
When is out-of-network coverage worth paying for?
Out-of-network coverage is worth paying for when a doctor you can’t replace is outside every affordable network, or when you spend long stretches away from home. For most people whose doctors are in network, an HMO or EPO costs less overall.
A PPO may make sense if a key specialist is out of network for every HMO and EPO nearby, you split the year between two states, or you are mid-treatment with a provider you don’t want to leave.
Remember that out-of-network spending has no yearly cap. If you qualify for cost-sharing reductions, check whether a Silver HMO or EPO that includes your doctors beats a PPO on total yearly cost. Our health insurance marketplace guide explains how to see every plan type sold in your county.
How Honesty checks networks for you
Honesty®, a licensed AI insurance agent from Honesty® Insurance Services, LLC (NPN 21094885), checks your doctors, hospitals and prescriptions against each plan before you choose. It compares ACA, alternative and ancillary plans side by side, without steering you to any carrier.
- Network and drugs first. Tell it who you see and what you take, and it flags which plans in your ZIP code include them.
- Unbiased. It compares plans by your family’s needs and never steers you to a carrier.
- Your data stays yours. We never sell or share it, and there are no spam calls.
- Enroll in minutes, 24/7. Licensed in 49 states and DC, by chat, voice or text.
Learn more about how Honesty.AI works, why unbiased advice matters and how a licensed health insurance broker differs from enrolling on your own. Ready to price plans? Start with health insurance quotes.
Find plans that include your doctors
Honesty.AI checks networks, drug lists and your 2027 subsidy, compares ACA, alternative and ancillary plans for your family’s needs, and enrolls you in minutes, 24/7. We never sell or share your data.
Frequently asked questions
What is the difference between in-network vs out-of-network?
In-network providers have a contract with your health plan and accept its negotiated rates, so you pay less and your costs count toward your out-of-pocket maximum. Out-of-network providers have no contract, so you pay more, the costs may not count toward your limits, and you can be balance billed.
Does an HMO cover out-of-network care?
Generally no. HMO and EPO plans cover out-of-network care only in an emergency. PPO and POS plans cover some out-of-network care at a higher cost.
Do out-of-network costs count toward my out-of-pocket maximum?
No. HealthCare.gov says costs for out-of-network care don’t count toward the out-of-pocket maximum. For 2027 the maximum for in-network covered care is $12,000 for one person and $24,000 for a family.
Can I be billed out-of-network rates for emergency care?
Usually not. Under the No Surprises Act, emergency services must be treated on an in-network basis without prior authorization, and your cost-sharing can’t be higher than in network. Ground ambulance rides are generally not protected.
How do I know if my doctor is in network?
Search the insurer’s directory using the exact plan and network name, use the doctor filter on HealthCare.gov or your state exchange, and call the office to confirm for 2027.
What happens if my doctor leaves my plan’s network?
If you are a continuing care patient, such as someone pregnant or scheduled for nonelective surgery, your plan must let you keep in-network terms with that provider for up to 90 days from its notice.
Keep learning: how health insurance works, Bronze vs Silver vs Gold vs Platinum, individual health insurance and the cheapest health insurance options.
