Is out-of-network care covered by insurance?
Seeing a doctor or facility that isn’t in your plan’s network. Here’s how each kind of plan usually handles it.
- Employer or MarketplaceCovered with conditions
Most job-based plans pay part of it at a higher cost: PPO and POS plans (about 6 in 10 workers) do; HMO and EPO plans pay only for emergencies.
More details
and POS plans cover out-of- care at a lower level, often with a separate deductible, and the provider can bill you the difference. HMOs and EPOs cover out-of-network care only in emergencies. The No Surprises Act protects you in the ER, from most out-of-network doctors at an in-network hospital or surgery center, and for air ambulances: you pay only your in-network share.
- Original MedicareUsually covered
Original Medicare has no network: any provider that accepts Medicare works.
More details
Doctors who don’t accept assignment can charge up to 15% more than the Medicare-approved amount.
- Medicare AdvantageCovered with conditions
Only emergencies and urgent care in an HMO (6 in 10 members); any provider who takes Medicare in a PPO, at a higher cost.
More details
Every plan must pay for emergency and urgently needed care anywhere in the U.S., in or out of . HMOs pay for nothing else out of network unless the plan approves it (HMO-POS plans pay for some); PPOs pay out-of-network providers who accept Medicare, with higher cost sharing and a higher yearly limit (about $9,800 combined on average in 2026, against about $6,600 in network).
- MedicaidUsually not covered
Usually not, except emergencies or approved exceptions.
More details
Medicaid health plans generally make you use doctors in their unless the plan approves an exception.
What usually has to be true
- Your plan type (HMO, PPO, EPO, POS) controls out-of-network benefits.
- Emergency care is protected regardless of network.
Good to know
- Out-of-network costs often don’t count toward your in-network out-of-pocket maximum.
- You can request a network adequacy exception if no in-network provider is available.
- If your doctor leaves the network while you’re in active treatment for a serious condition, pregnant, or scheduled for surgery, federal law lets job-based and Marketplace plan members keep in-network costs with that doctor for up to 90 days. Ask your plan for continuity of care.
Related
- Specialist visit · Dermatologists, cardiologists, GI doctors, orthopedists, and other specialists.
- Emergency room · Emergency department care for serious injuries or symptoms.
Sources
Typical rules for 2026 plans, checked against these sources on October 20, 2026. Your plan’s own documents decide.
- 12026 Employer Health Benefits Survey
KFF
Fifty percent of covered workers are enrolled in PPOs in 2026, followed by HSA-qualified plans (29%), HMOs (12%), and POS plans (8%). In 2026, 71% of covered workers are in a self-funded health plan. Among firms with 200 or more workers, 18% cover GLP-1 drugs for weight loss and 27% cover IVF. Most covered workers (82%) are in plans with three or more drug cost-sharing tiers; average copays are $12, $36, $66, and $136 by tier.
- 2Know your rights when using insurance
Centers for Medicare & Medicaid Services
Federal law limits many surprise out-of-network bills for emergency care and certain services at in-network facilities, with exceptions.
- 3What Marketplace plans cover
HealthCare.gov
Marketplace plans cover outpatient care, hospitalization, mental health care, prescription drugs, rehabilitation, laboratory services, preventive services, and other essential benefit categories.
- 4Doctor and other provider services
Medicare.gov
Part B covers medically necessary doctor services, including outpatient and some inpatient services; you generally pay 20% of the approved amount after the deductible.
- 5Compare Original Medicare and Medicare Advantage
Medicare.gov
Medicare Advantage plans cover everything Original Medicare covers (except hospice, which Original Medicare continues to pay), usually use provider networks, often require referrals or prior authorization, and may offer extra benefits such as dental, vision, and hearing.
- 6Medicare Advantage in 2026: Premiums, Out-of-Pocket Limits, Supplemental Benefits, and Prior Authorization
KFF
Most enrollees in individual plans are in plans with dental care (98%), eye exams and/or glasses (more than 99%), hearing exams and/or aids (95%), and a fitness benefit (91%). Fewer have over-the-counter benefits (68% in 2026 vs 79% in 2025), bathroom safety devices (21% in 2026 vs 32% in 2025), and transportation benefits (22% in 2026 vs 28% in 2025). Most enrollees are in HMOs (61%), 38% are in local PPOs, and less than 1% are in regional PPOs in 2026.
- 742 CFR 422.113: Special rules for ambulance services, emergency and urgently needed services
Code of Federal Regulations
The MA organization is financially responsible for emergency and urgently needed services regardless of whether the services are obtained within or outside the MA organization, and regardless of whether there is prior authorization for the services.
- 8Mandatory and optional Medicaid benefits
Medicaid.gov
States must cover mandatory benefits such as inpatient and outpatient hospital care, physician services, laboratory and X-ray services, home health, and nursing facility care; many other benefits, including adult dental, vision, and prescription drugs coverage details, are state options.
General information about how coverage usually works, not a decision about your plan. Your plan documents and insurer have the final word.