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Cost of Out-of-Network Doctors & Hospitals

You can keep your out-of-pocket costs down when you stay in network. We discuss rates with providers to help you save money. We refer to these providers (such as doctors, hospitals, and surgical centers) as being “in our network.”

There may be times when you decide to visit a doctor or hospital not in the network. Some plans cover out-of-network care only in an emergency. Otherwise, you’re responsible for the full billed amount. For plans that do cover out-of-network care, you’ll usually pay more than if you stayed in the network.

See how much less it can cost to stay in network

Some plans don’t offer any out-of-network benefits. For those plans, out-of-network care is covered only in an emergency. Otherwise, you’re responsible for the full billed amount of any care you get out of network.

The information on this page is for plans that offer both in-network and out-of-network coverage.

These plans pay for out-of-network services based on an “allowed” amount. Most Allina Health | Aetna plans determine the allowed amount based on what Medicare would pay, or on a “reasonable” amount. Your plan documents will tell you how your plan decides the allowed amount.

We’ll use an example to show you how out-of-pocket costs are calculated for care when you stay in network and when you go out of network.

Let’s look at an $825 charge from a doctor’s visit.

In network, your cost for this visit is $140. Out of network, it’s $645. So you pay an extra $505. Here’s why:


How does going out of network affect out-of-pocket limits?

An out-of-network doctor can charge any amount he or she wants. He has not agreed to a contract price for the covered service. In this case, the doctor is charging $825. Not all of that money counts toward your out-of-pocket limit.

  • Your out-of-network deductible ($100) counts toward your out-of-pocket limit.
  • Your coinsurance ($120) counts toward your out-of-pocket limit.
  • The extra amount the doctor can bill ($425) does not count toward your out-of-pocket limit. 

How to lower your costs

Ask your doctor to refer you to a specialist, hospital or surgical center that accepts your plan.

Or search our provider directory

Find out what it will cost before you go. Ask your out-of-network providers what the billed amount will be. For in-network care, your secure member website may be able to provide rate estimates. Or talk with the in-network provider’s office about what you may be asked to pay.

Does your member ID card have “NAP” on the front? NAP stands for National Advantage™ Program. With this program, you can:

  • Get discounts for out-of-network care from NAP providers. Your out-of-pocket costs may be less than your costs for seeing other providers who are out of network..
  • Avoid a balance bill by getting care from a NAP provider. You’ll pay your usual cost sharing for out-of-network care. .

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

Effective solutions that fit a variety of needs

Our health coverage solutions bring together local expertise with the experience of a leading national insurance brand. We provide plans that deliver the services members value with the type of cost clarity that gives peace of mind.

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Legal Notices: Health benefits and health insurance plans contain exclusions and limitations.

Health benefits and health plans are offered, underwritten or administered by Allina Health and Aetna Insurance Company (Allina Health | Aetna).  Allina Health l Aetna is an affiliate of Aetna Life Insurance Company and its affiliates (Aetna).  Allina Health | Aetna has sole responsibility for its products and services. Aetna provides certain management services to Allina Health | Aetna. Aetna and MinuteClinic, LLC (which either operates or provides certain management support services to MinuteClinic-branded walk-in clinics) are both within the CVS Health family.

Allina Health | Aetna is the brand name used for products and services provided by Allina Health and Aetna Insurance Company.

This material is for information only and is not an offer or invitation to contract. Health benefit plans contain exclusions and limitations. Providers are independent contractors and not our agents. Provider participation may change without notice. We do not provide care or guarantee access to health services. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability are subject to change and may vary by location. If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to specialists and hospitals that are part of the delivery system or physician group. Information is believed to be accurate as of the production date; however, it is subject to change.

*Applies only to covered services at MinuteClinic. Members in indemnity plans are not eligible for this benefit. Such members should refer to their benefit plan documents in order to determine coverage and applicable cost share for walk-in clinic benefits and services, as applicable. Visit for age and service restrictions. Eligible members enrolled in qualified high-deductible plans must meet their deductible. However, such services would be subject to negotiated contract rates. Once the deductible has been met, members will be able to access MinuteClinic services at no cost share. Aetna and MinuteClinic, LLC (which either operates or provides certain management support services to MinuteClinic-branded walk-in clinics) are both within the CVS Health family. Aetna is not responsible for services received at MinuteClinic locations. 98point6 and 98point6 physicians are independent contractors and are neither agents nor employees of Allina Health | Aetna or plans administered by Allina Health | Aetna and does not guarantee that a prescription will be written.

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