In Network vs Out of Network Deductible: 5 Easy Checks

The in network vs out of network deductible question comes up whenever a client’s plan has separate amounts for each. HealthCare.gov defines a network as the facilities, providers and suppliers the insurer or plan has contracted with, so out-of-network care is care from providers who have no such contract.

This guide covers commercial plans, which are private payers. Medicare and Medicaid follow different rules. It is written for therapists and psychiatrists, in or out of network.

In network vs out of network deductible: what is different

Topic	In network	Out of network
Provider contract	The provider is contracted with the plan.	The provider is not contracted with the plan.
Balance billing	Per HealthCare.gov, a preferred provider may not balance bill for covered services.	The provider may bill the difference between the charge and the allowed amount, which HealthCare.gov calls balance billing.
Out of pocket limit	In-network deductibles, copays and coinsurance count toward it.	Per HealthCare.gov, out-of-network care is not included in the limit.
Deductible	Tracked as the in-network deductible.	Many plans track a separate amount, so read the out-of-network line.

Terms such as allowed amount and balance billing are explained in our patient financial responsibility terms.

Five checks on the eligibility response

1. Whether the plan covers out-of-network mental health care at all.
2. The out-of-network deductible and how much has been met.
3. The coinsurance or copay that applies after it.
4. How the plan sets the allowed amount, since it may differ from your fee.
5. The plan year start date, because both deductibles restart then.

Our patient benefit verification checklist lists the full set of questions.

What the client needs to hear

A client seeing you out of network needs a clear estimate before the first visit: the deductible they may owe, the share after it, and any difference between your fee and the allowed amount. Put it in writing. Our Good Faith Estimate guide covers estimates for self-pay clients.

Why January makes the gap bigger

At the new plan year every deductible restarts. A client who finished the year paying nothing can owe the full allowed amount again, in network or out. The insurance deductible reset for therapists guide covers the January workflow.

Where out-of-network claims go from here

If your practice is out of network with a payer, see our guides on out-of-network billing for therapists and out-of-network billing for group practices. For the credentialing side, read in-network vs out-of-network credentialing. For denials, use the claim denials and appeals resource and the Resources hub.

In network vs out of network deductible: the short version

• In network vs out of network deductible amounts can be tracked separately, so read both lines.
• Out-of-network care is not included in the out of pocket limit on the HealthCare.gov definition.
• Give clients a written estimate before the first visit.
• Re-verify at every plan year start.

How MCM South helps

MCM South handles insurance verification, claims submission and denied claim follow-up for therapists and psychiatrists. MCM South bills out-of-network claims for clients, and checking the in network vs out of network deductible figures first keeps the patient balance clear.

In network vs out of network deductible FAQ

Where MCM South works

MCM South works only in mental and behavioral health. We serve psychotherapists and psychiatrists in solo and medium-size practices across ten currently served states: Georgia, Massachusetts, Connecticut, Texas, Florida, New York, Colorado, Tennessee, North Carolina and Illinois. Need a payer contact? Use our insurance companies contact directory.