What happens if I see an out-of-network provider in an emergency?

US federal law (the No Surprises Act, effective 2022) protects patients from unexpected bills for emergency care at out-of-network facilities. You generally pay only what you would have paid in-network. The CMS No Surprises Act guidance explains your rights in detail.

How do I check whether a doctor is in my network?

Your insurer's website should have a "find a provider" or "network search" tool. Always confirm directly with the provider's office before the visit — networks change frequently and the insurer's directory is not always up to date. The HealthCare.gov plan finder includes network search for marketplace plans.

Can I have both in-network and out-of-network cover on the same plan?

Yes — PPO (Preferred Provider Organisation) plans allow you to see any provider, but charge you less for in-network providers. HMO (Health Maintenance Organisation) plans typically only cover in-network care except in emergencies. EPO (Exclusive Provider Organisation) plans are similar to HMOs but may not require a referral.

Does "in network" mean the same thing in the UK and Australia?

The terminology differs. UK private health insurance often uses "recognised providers" or "approved hospitals." Australian private health insurance uses "agreement hospitals." The principle is the same: the insurer has agreed rates with certain providers, and you pay less (or nothing) when you use them. Check your policy schedule for your insurer's specific network details.

Guide Health 5 min read Reviewed 2026-10-14

Provider networks: what "in network" means for you

Why the same doctor visit can cost ten times more depending on whether they are in your insurer's network — and how to check before you book.

What is a provider network?

A provider network is a group of doctors, hospitals, specialists, and other healthcare providers that have contracted with your insurer to provide care at pre-negotiated rates. Because the insurer channels patients to these providers and guarantees payment, the providers offer discounted rates. You benefit by paying less — usually just your copay or coinsurance — rather than the full bill.

When you use an out-of-network provider, the insurer has no rate agreement with them. Depending on your plan type, the insurer may pay nothing, pay a reduced amount at "usual and customary" rates, or pay at your out-of-network benefit level with a separate (higher) deductible. The HealthCare.gov network glossary explains how this works for US marketplace plans.

Main network plan types (US)

HMO

Health Maintenance Organisation

In-network only (except emergencies). Requires a primary care physician (PCP) and referrals to see specialists. Lower premiums, less flexibility.

PPO

Preferred Provider Organisation

In-network and out-of-network care both covered. No referral required. Higher premiums, maximum flexibility.

EPO

Exclusive Provider Organisation

In-network only (except emergencies). No referral required for specialists. Moderate premiums.

POS

Point of Service

Hybrid of HMO and PPO. Requires referrals for in-network specialists but allows out-of-network care at higher cost.

How much more does out-of-network cost?

The difference can be substantial. For a PPO plan with a $1,500 in-network deductible, the out-of-network deductible might be $4,500 — three times higher. Coinsurance may be 20% in-network and 40% out-of-network. And the out-of-network out-of-pocket maximum is typically much higher or unlimited.

In the worst case — an HMO or EPO plan where out-of-network is not covered — you bear 100% of the cost. The KFF research on surprise billing found that one in five emergency visits generates an unexpected out-of-network charge.

How to check before you book

Use your insurer's online provider directory to search by name, specialty, or zip code.
Call the provider's office and ask them to confirm their network status with your specific insurer and plan name (not just the insurer — networks vary by plan).
If you are referred to a specialist, confirm the specialist's network status, not just the referring doctor's.
For hospital care, confirm both the hospital and all treating physicians (anaesthesiologists, radiologists) are in-network — each bills separately.

For help understanding how deductibles and cost sharing work alongside network costs, see our guides to deductibles and out-of-pocket maximums and coinsurance and copays.

Provider network FAQ

Frequently asked questions

: US federal law (the No Surprises Act, effective 2022) protects patients from unexpected bills for emergency care at out-of-network facilities. You generally pay only what you would have paid in-network. The CMS No Surprises Act guidance explains your rights in detail.
: Your insurer's website should have a "find a provider" or "network search" tool. Always confirm directly with the provider's office before the visit — networks change frequently and the insurer's directory is not always up to date. The HealthCare.gov plan finder includes network search for marketplace plans.
: Yes — PPO (Preferred Provider Organisation) plans allow you to see any provider, but charge you less for in-network providers. HMO (Health Maintenance Organisation) plans typically only cover in-network care except in emergencies. EPO (Exclusive Provider Organisation) plans are similar to HMOs but may not require a referral.
: The terminology differs. UK private health insurance often uses "recognised providers" or "approved hospitals." Australian private health insurance uses "agreement hospitals." The principle is the same: the insurer has agreed rates with certain providers, and you pay less (or nothing) when you use them. Check your policy schedule for your insurer's specific network details.