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 |

Plans are not required to cover any care received from a non-network provider; some plans today do cover out-of-network providers, 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 out-of-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. Out-of-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 unless it is a situation covered by state or federal protections against such bills, including emergency care or an out-of-network provider at an in-network facility.

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—you can appeal the insurer’s decision. If you inadvertently got out-of-network care while at an in-network hospital, for example, if the anesthesiologist or other physicians working in the hospital don’t participate in your plan network, contact your health plan or insurer. Federal protections that took effect January 1, 2022, may prevent the provider from sending you a surprise medical bill for charges not covered by your insurer and you can ask for an internal appeal and external review. 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).

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