out of network (out of plan)

This phrase usually refers to physicians, hospitals or other healthcare providers who do not participate in an insurer’s provider network. This means that the provider has not signed a contract agreeing to accept the insurer’s negotiated prices.

Depending on an individual’s health insurance plan, expenses incurred for services provided by out-of-plan health professionals may not be covered, or may only be partially covered by an individual’s insurance company. Plans that cover out-of-network care are less common than they once were, but they are still available in many areas. They generally impose a higher deductible and out-of-pocket limit (or even no upper limit) when patients obtain care from an out-of-network provider.

And it’s important to understand that out-of-network providers can and do balance bill patients for the remainder of the charges after the insurance company has paid its share. In-network providers have agreed to accept the insurance company’s payment (plus the patient’s pre-determined cost-sharing amount) as payment in full, but out-of-network providers have not signed any sort of agreement with the insurer.