Cost of Out-of-Network Doctors & Hospitals

People are paying more of their health care costs these days. It’s no wonder there is a lot of interest in keeping these costs down.

A smart way to do this is to avoid using doctors and hospitals that are “out of network.” We do not have a contract for reduced rates with an out-of-network doctor or hospital. So you could end up with higher costs and more work.

Why out-of-network costs more

There are many reasons you probably will pay more out of pocket:

The health plan pays less

  • Your Aetna health benefits or insurance plan may pay part of the doctor’s bill. But it pays less of the bill than if you get care from a network doctor.
  • Some plans may not pay any benefits if you go out of network. Some plans cover out-of-network care only in an emergency.

Cost sharing is more

With most plans, your coinsurance is higher for out-of-network care.  Coinsurance is the part of the covered service you pay for (e.g. the plan pays 80% of the covered amount and you pay 20% coinsurance).

Out-of-network rates are higher

  • An out-of-network doctor sets the rate to charge you. It is usually higher than the amount your Aetna plan “recognizes” or “allows.”
  • An out-of-network doctor can bill you for anything over the amount that Aetna recognizes or allows. This is called “balance billing.” A network doctor has agreed not to do that.
  • We do not base our payments on what the out-of-network doctor bills you. We do not know in advance what the doctor will charge.

Deductibles are separate, higher

  • What you pay when you are balance billed does not count toward your deductible.  And it is not part of any cap your plan has on how much you have to pay for covered services.
  • Many plans have a separate out-of-network deductible. This is higher than your in-network deductible (sometimes, you have no deductible at all for care in the network). You must meet the out-of-network deductible before your plan pays any out-of-network benefits.

You’ll have more work, too

Plus, when you visit an out-of-network doctor, you handle precertification, if needed. This means more time and more paperwork for you.

Know your costs before you go

Before you decide where to receive care, look up your estimated costs for that care if you were to stay in-network. It’s easy with our cost of care tools. If you’re a member, log in to your secure Aetna Navigator® website to use these tools.

We do not know what an out-of-network doctor will charge you.  Check with your out-of-network doctor what they will charge you.  Then make a decision based on what is right for you.

You are covered for emergency care

You are covered for emergency care. You have this coverage while you are traveling or if you are near your home. That includes students who are away at school.

Sometimes you don’t have a choice about where you go for care.  Like if you go to the emergency room for a heart attack or a car accident.  When you need care right away, go to any doctor, walk-in clinic, urgent care center or emergency room.  When you have no choice, we will pay the bill as if you got care in network. You pay your plan’s copayments, coinsurance, and deductibles for your in-network level of benefits.

We’ll review the information when the claim comes in. If we think the situation was not urgent, we might ask you for more information and may send you a form to fill out. Please complete the form, or call Member Services to give us the information over the phone.

How we determine what to pay for out-of-network care

The plan you or your employer pick determines how much you pay for care out of the network. The exact amount depends on the:

  • Method your plan uses to set the recognized or allowed amount
  • Percent of the allowed amount to be paid by the plan (like 80% or 60%)
  • To find the method and percent, check your plan documents. Or call Member Services at the toll-free number on your ID card.

Take a look at some examples of how your benefits pay for care.

Want to stay in our Network?
  • Ask your doctor to refer you to a provider (e.g. hospital, surgical center, specialist) in Aetna’s network
  • Login to DocFind to determine what doctors and hospitals are in Aetna’s network

Still have questions?

  • Contact us by e-mail on your secure member website at
  • Call us at the number on the back of your ID card.

Some out-of-network care is discounted

Does your Aetna ID card have “NAP” on the front? That stands for National Advantage™ Program. And it has benefits for you:

  • You can get discounts for out-of-network care. Your out-of-pocket costs may be less than your costs for seeing other providers who are out of network.
  • If you get care from a NAP provider, some doctors or hospitals might not balance bill you. This is true even though the NAP provider is out of network.

Check your most recent ID card to see whether your plan has the program. Some plans that used to have NAP no longer have the program.

Do you have large out-of-network claims?

Did you go to an out-of-network doctor or hospital, and then get surprised with a very large bill? Sometimes a provider will allow you to pay a reduced fee. Sometimes they will work out a payment plan for you. You may be able to work this out with the provider by yourself.  You also can get professional support.  Here’s how that works.

You can get that support if you:

  • Used your out-of-network benefits
  • Did not receive a discount through the NAP program, and
  • Have more than $1,000 in out-of-pocket costs for a single health care event AFTER your deductible, copay or coinsurance

As an Aetna member, you can get discounted services with a claims negotiating company. The company, the Karis Group, has been helping individuals with outstanding medical bills nationally since 1996.

For an affordable fee, the Karis Group will negotiate with the provider for you. They may be able to reduce the amount you owe or arrange a payment plan. They also may be able to qualify you for programs to resolve your balance due.

As an Aetna member, you will receive a large discount for these services. They can’t guarantee they will be successful. But if they don’t get any results for you, they will refund your fee.

Are you interested in this service? Here’s how you can learn more:

While Aetna has arranged for this discount for our members, we are not part of any agreements between our members and the Karis Group.  We honor your privacy.  We do not share our member information with the Karis Group.

Health benefits and health insurance plans are offered and/or underwritten by Aetna Health Inc., Aetna Health of California Inc., Aetna Health Insurance Company of New York, Aetna Health Insurance Company and/or Aetna Life Insurance Company (Aetna).  In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company.  In Maryland, by Aetna Health Inc., 151 Farmington Avenue, Hartford, CT 06156.  Each insurer has sole financial responsibility for its own products.


This material is for information only and is not an offer or invitation to contract.  Plans may be subject to medical underwriting or other restrictions.  Rates and benefits vary by location.  Health benefits and health insurance plans contain exclusions and limitations.  Providers are independent contractors and are not agents of Aetna.  Provider participation may change without notice.  Aetna does not provide care or guarantee access to health services.  Information is believed to be accurate as of the production date; however, it is subject to change.

Policy forms issued in OK include:  HMO OK COC-5 09/07, HMO/OK GA-3 11/01, HMO OK POS RIDER 08/07, GR-23 and/or GR-29/GR-29N.


JavaScript is required

In order to have the best experience on, Javascript needs to be enabled.
Learn how to change your browser settings to enable Javascript.

You are now leaving the Aetna website

Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.

Continue >

I'm shopping for

Shopping for your area is currently served by a different website.


Shop for a plan

Shopping for your area is currently served by a different website.


Shop for a plan

We have plans in your zip code through Coventry One, an Aetna affiliate.


Shop for a plan

We have plans in your zip code through Coventry One, an Aetna affiliate.


Shop for a plan

We have plans in your zip code through Innovation Health, an Aetna affiliate.


Shop for a plan

We have plans in your zip code through Innovation Health, an Aetna affiliate.


Speak with an agent

Please enter a valid ZIP code

You have entered an invalid zip code. Please try again.


Shop for a plan Speak with an agent

Please enter your ZIP code
Please enter a valid ZIP code


You’ll find excellent plans for seniors on our Medicare site.




You’ll find excellent plans for seniors on our Medicare site.


Speak with an agent


You’ll find great plans on our Aetna Student Insurance website




You’ll find great plans on our Aetna Student Insurance website


Speak with an agent


You’ll find great insurance for expats on our Aetna International site




You’ll find great insurance for expats on our Aetna International site


Speak with an agent