If you need care from a provider that is outside of your network (and thus does not have a contract with your health plan), each Marketplace health plan will have policies and procedures for reimbursing the out-of-network provider. 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 when you are outside of your service area.
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. Additionally, federal balance billing protections prevent providers from sending you a surprise medical bill for emergency medical charges not covered by your insurer. To learn more about federal protections against surprise medical bills, visit https://www.cms.gov/nosurprises.
(42 U.S.C. § 300gg–19a(b); CCIIO, Affordable Care Act Implementation FAQs - Set 1; Consolidated Appropriations Act, 2021, Pub. L. No. 116-260, 134 Stat. 1182.)