Out of network means a provider has no contract with your plan. There is no negotiated rate, so the provider bills its own charge, the plan pays whatever its out-of-network benefit allows if it has one, and the difference is a question rather than a given.

The word does more work than people expect, because it attaches to each biller separately. An in-network hospital can host an out-of-network anaesthesiologist. An in-network physician can send your sample to an out-of-network lab. An in-network imaging centre can use an out-of-network radiologist to read the scan. In every one of those cases the patient chose correctly and still ends up with an out-of-network bill.

In New York: the state has more protection here than most, and the protection depends on how you ended up out of network.

If you did not choose it, in an emergency or as a surprise bill at a participating facility, New York’s surprise billing framework applies and the argument over the amount goes to independent dispute resolution between the provider and the plan rather than to you. An uninsured patient may file an IDR application themselves for an emergency-services bill they believe is excessive.

If you did choose it, deliberately seeing an out-of-network clinician, the rules do not rescue you and the questions are different: what your out-of-network benefit is, what the out-of-network deductible is, and whether the provider will give you a superbill to submit yourself.

The gap that catches people: the federal No Surprises Act does not cover ground ambulances, only air ones. And whether New York’s protections reach your bill at all depends on your plan type, because a self-funded employer plan is governed by federal law rather than state law. Ask HR: “Is our plan fully insured or self-funded?”

For behavioral health, out-of-network is less an exception than the norm in New York, since a large share of therapists take no insurance at all. That is a network adequacy problem with its own method and its own complaint route. How to work it.

Also called: non-participating, nonpar, out of plan. Full guide: Surprise medical bills in New York.

More in Glossary of health coverage and billing terms

  • Navigator — A certified, free helper who walks you through enrollment and earns no commission on your choice.
  • Sliding scale fee — A sliding scale fee is a price set by household income and size. How the scales at NYC community health centers and NYC Care work, and what to bring.
  • Good faith estimate — A good faith estimate is the written cost estimate uninsured and self-pay patients are owed before scheduled care. What it must list, and the $400 rule.
  • Network (in-network and out-of-network) — The set of doctors and hospitals your plan has contracted with. Outside it, you pay much more.
  • Balance billing — Balance billing is a provider billing you the gap between its charge and your plan's allowed amount. When New York bars it, including Medicare's 5% cap.

This page explains how the system works. It is not medical advice. More.