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

In general, plans are not required to cover care received from an out-of-network (OON) provider. For example, if you choose to visit a primary care doctor that is not in your plan’s provider network, your insurer might not pay any of the bill, or if they do, you might have much higher cost-sharing than if you had chosen to see an in-network provider.

In these situations, the health care provider or facility might send you a bill for the difference between what your insurance covers (if any) and what the provider actually charges. This type of bill is known as a “balance bill” or “surprise medical bill.” However, there are three situations in which providers generally cannot send you a balance bill:

1.  If you received emergency or post-emergency stabilization care at an OON facility or from an OON provider; or

2. If you unintentionally received care from an OON provider while at an in-network hospital (for instance, if the anesthesiologist or other specialist isn’t in your plan’s network); or

3. You were transported by an out-of-network air ambulance in either of the previous two situations.

You can learn more about these federal protections here.

If you received a surprise medical bill after choosing an OON provider, you can submit an internal appeal to your insurance company and ask for an external review. Contact your state insurance department for more information on the appeals process, to see if there are programs to help you with your appeal, whether any other state protections may apply, or to file a complaint about a surprise medical bill. You can also visit the No Surprises Help Desk or call 1-800-985-3059 to submit a complaint or get more information.