Each marketplace health plan will have policies and procedures for reimbursing out-of-network providers (providers that are not under contract with your health plan). Since you may not have access to your health plan documents, calling the health insurance company and asking about your specific situation may be the best option. The contact information should be on your health insurance card. If you don’t have access to your health insurance card, contact the Marketplace Call Center (HealthCare.gov) at 1-800-318-2596 (TTY: 1-855-889-4325) or your state’s Department of Insurance. In addition, some health insurance companies may have information on their websites about how to access services and medication.
In emergency medical situations, the Affordable Care Act requires insurers to provide coverage for out-of-network care and prohibits insurers from charging higher coinsurance or copayment amounts for out-of-network care than for in-network care. The ACA, however, does not prohibit medical providers from billing consumers the “balance” of their charges after an insurer pays a portion of the charges. Some states have protections against this “balance billing,” in emergency situations including Florida, which prohibits medical providers from balance billing consumers when they receive emergency services by an out-of-network provider.