Non-network Services

Navigating any health care plan can be complicated. Just when you think you have it figured out, you stumble across some new jargon and legalese that only makes it more convoluted and frustrating. This is especially true when dealing with managed-care plans and provider networks. How do you get treatment from an out-of-network health care professional? In this article we'll look at how managed health care companies treat non-network services.

health care network
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Navigating your health care plan can be confusing.

Non-network services are any type of medical care outside the network of providers set up by your managed-care plan. Because most networks make every attempt to include the most common types of provider, like family-care doctors and pediatricians, there might not be a wide variety of specialists. The dermatologist or nutritionist you saw on one plan might not be available on another. Your doctor should refer you only to in-network specialists, but it can get tricky when the specialist you need is not included in the network.

So what happens if you do have to visit a non-network doctor? How much should you expect to pay?

Non-Network Services and Payment

If you're a member of an HMO, paying for out-of-network treatment is pretty straightforward: You pay for it all yourself. PPOs can get a bit more complicated. Typically, because PPOs are a bit more expensive than HMOs, you'll get some coverage when you go outside the network. Providing that you are receiving eligible services, and that your insurer has preapproved the treatment (if necessary), a percentage of your bill will be paid. For example, your insurer will pay for a visit to an in-network doctor for a simple problem, and you will be expected to pay a simple co-payment. However, a visit to the same sort of doctor, out of network, may be covered only 80 percent, so you'll have to fork out the remaining 20 percent in addition to your co-pay. This is known as coinsurance. This is true even if an in-network doctor referred you to the out-of-network provider. As we mentioned, your doctor should refer you to an in-network specialist. But if for some reason he or she sends you out-of-network, you should do some research and check if there is an in-network specialist.

Payment Methods
Obviously, if you're in a managed health care plan, you're going to avoid seeking treatment outside your network. But hypothetically, (assuming you've already met your annual deductible) the cost breakdown might go something like this: 

 In Network

 Out of Network

Provider bill



What insurers are allowed to charge 



Provider discount



What insurer pays 



What you pay



Fortunately, though, many managed health care providers are aware of how out-of-reach these costs can be for their customers. Some have found ways to deflect them by negotiating with the provider for you or setting up a fee schedule (payment plan). But if these measures are available, they usually have to be arranged in advance. Managed health care plans do everything they can to keep you within the network -- they don't go as far as forbidding you to seek care elsewhere, but financially speaking, it works out to be a kind of de facto prohibition.

For more information about non-network services, check out the links on the next page.

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More Great Links


  • Your Health Info: Medical Financing.
  • First Health: Non-Network Fees.
  • National Library of Medicine.
  • Family Doc: Understanding Your Health Plan's Rules.