QUESTION

What happens if I end up needing care from a doctor who isn’t in my plan’s network?

Post enrollment issues | Individual Health Insurance
ANSWER

Plans are not required to cover any care received from a non-network provider, though some plans today do, although often with much higher co-payments or coinsurance than for in-network services (e.g., 80 percent of in-network costs might be reimbursed but only 60 percent of non-network care.) In addition, when you get care out-of-network, insurers may apply a separate deductible and are not required to apply your costs to the annual out-of-pocket limit on cost-sharing. Non-network providers also are not contracted to limit their charges to an amount the insurer says is reasonable, so you might also owe “balance billing” expenses.

If you went out-of-network because you felt it was medically necessary to receive care from a specific professional or facility – for example, if you felt your plan’s network didn’t include providers able to provide the care you need – or if you inadvertently got non-network care while hospitalized if the anesthesiologist or other physicians working in the hospital don’t participate in your plan network – you can appeal the insurer’s decision. Contact your state insurance department to see if there are programs to help you with your appeal and more information on how to appeal. (45 C.F.R. § 156.130; 45 C.F.R. § 147.136).

Individuals with no coverage
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Post enrollment issues