Finding a doctor you trust can feel like winning the healthcare lottery—but what happens when your trusted provider isn’t covered by your new insurance plan? Whether you’ve switched employers, joined a new ACA Marketplace plan, or moved to a different state, you may face the frustration of discovering your preferred doctor is out of network.
Out-of-network care usually means higher costs—or no coverage at all. But don’t panic: you have options. In this article, we’ll explain what it means when a provider is out of network, why networks exist, and what steps you can take to keep seeing your doctor or find an equally qualified alternative.
What Does “Out of Network” Mean?
Health insurance companies build networks of contracted providers—doctors, hospitals, labs, and clinics that agree to provide services at negotiated rates. These providers are considered “in network.”
When a provider isn’t contracted with your plan, they’re considered “out of network”. This distinction matters because:
In-network care typically costs much less and counts toward your deductible and out-of-pocket maximum.
Out-of-network care may cost more—or may not be covered at all, depending on your plan type.
Plans like PPOs (Preferred Provider Organizations) offer some out-of-network coverage. Others—like HMOs (Health Maintenance Organizations) and EPOs (Exclusive Provider Organizations)—often cover only in-network care except in emergencies.
First, Double-Check the Network Status
Before assuming your doctor is out of network:
Log into your insurer’s website or mobile app and search the provider directory
Call your doctor’s office and ask which insurance plans they accept
Confirm the tax ID or NPI (National Provider Identifier) the office uses to bill—some providers work under multiple networks or locations
Network status can vary by location, insurance company, and plan year. Always confirm with both the doctor’s office and your insurance provider.
If Your Doctor Is Out of Network, You Have Options
1. Ask if the Doctor Will Join Your Plan’s Network
It’s rare, but worth asking. Sometimes doctors are willing to join new networks if enough patients request it or if the plan offers favorable reimbursement. Your insurer may even help initiate that conversation.
2. See if You Can Negotiate a Lower Cash Rate
If your doctor won’t join the network, ask if they offer a self-pay discount. Many providers will offer lower rates for patients paying out of pocket, especially if you don’t involve insurance. Ask for the price of specific services in advance.
3. Request a “Continuity of Care” Waiver
Some insurance companies offer temporary exceptions to let you continue seeing an out-of-network provider—especially if you’re in the middle of treatment for:
Pregnancy
Cancer
Recent surgery
Chronic illness
Mental health care
This is called a continuity of care waiver or transition of care exception. It’s often limited to 60–90 days and must be requested in writing.
Check your insurer’s policy or contact customer service to request the necessary forms.
4. File an Appeal for Coverage
If your doctor is out of network and your plan denies a claim, you have the right to appeal the decision. Your appeal may succeed if:
No in-network provider offers the same level of care
You needed emergency treatment
You were referred by an in-network provider but had no other covered options
You’ll need to submit documentation, including a letter of medical necessity from your provider. This process can take time—but it’s worth pursuing if the costs are substantial.
Learn more about appeals: Healthcare.gov – Appeals
5. Consider Switching Plans During Open Enrollment
If you know you want to keep seeing a specific doctor, consider choosing a plan that includes them in the network during your next open enrollment period. Use tools like:
Your state Marketplace’s search tool
Your insurer’s provider directory
Make sure to search by the provider’s name, location, and specialty, and confirm before enrolling.
What About Out-of-Network Billing?
If you receive care from an out-of-network provider, you may face:
Higher coinsurance rates
Separate deductibles
No out-of-pocket cap for that care
Surprise balance billing
However, the No Surprises Act, which took effect in 2022, offers important protections:
Emergency care at any hospital must be covered at in-network rates—even if the provider is out of network
Ancillary services (like anesthesia) at in-network facilities can’t send balance bills
Providers must give advance notice and get your consent before billing you more for out-of-network care in many situations
If you believe you’ve been wrongly billed, file a complaint at CMS’s No Surprises Help Desk
Tips for Finding an In-Network Alternative
If sticking with your current doctor isn’t financially realistic, finding a new provider can feel overwhelming. Here’s how to simplify the process:
Use your insurer’s online directory, filtering by specialty and ZIP code
Call offices directly to confirm they’re accepting new patients
Read reviews on third-party sites (e.g., Healthgrades, Zocdoc)
Ask your current doctor for referrals to trusted colleagues in-network
Look for telehealth options, which are often more flexible and lower-cost
You might find a new provider you like just as much—or more—especially if your current doctor’s fees were already a stretch.
Bottom Line
If your doctor is out of network, it doesn’t necessarily mean the end of the road. From negotiating rates to requesting coverage exceptions to exploring new providers, you have options to keep your care affordable and continuous.
Being proactive, asking questions, and understanding your rights can help you make the best choice for your health and your wallet.
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