Forum Session

Going Out of Network: Why It Happens, What It Costs, and What Can Be Done
December 6, 2013


Sally Coberly, PhD


A health plan's network of providers is an important consideration for many people purchasing health insurance. This is true not only because most people want to make sure their current providers participate in the plan they choose, but also because using out-of-network providers can have significant financial consequences including higher copays and, in some instances, additional charges by the provider known as balance billing. While larger networks appeal to many consumers, in part because they reduce the likelihood of needing an out-of-network provider, they are typically more costly to the insurer. In an effort to reduce premium costs, many plans offered on the new marketplace exchanges through the Patient Protection and Affordable Care Act of 2010 (ACA) are likely to have narrow networks, which may put newly insured individuals at greater risk of using out-of-network providers and possibly higher copays and balance billing. The ACA does provide some consumer protection around the costs incurred for out-of-network emergency care, but these protections do not extend to other services. Given the trend toward relatively limited networks in the exchanges and, increasingly, in the group insurance market, the question of who pays and how much when a plan member goes out of network takes on increased importance.

This Forum session reviewed the relationship between networks and consumers' health care costs; presented preliminary findings regarding the characteristics of networks in ACA marketplace plans; and discussed state and federal oversight and consumer protections regarding network adequacy, balance billing, and payment of out-of-network charges.


Kelly A. Kyanko, MD, MHS (bio)
Assistant Professor of Population Health and Medicine
New York University School of Medicine
Assistant Attending Physician
Bellevue Hospital Center

Dianne Longley (bio)
Health Management Associates

Kevin Lucia, JD, MHP (bio)
Senior Research Fellow
Center on Health Insurance Reforms
Health Policy Institute
Georgetown University

Related Materials

"Tiered Provider Networks: Steps to Cost Containment?" (Forum Session, June 24, 2011)

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