Marketplace Health Plans and Premiums

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

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In general, plans are not required to cover care received from a non-network provider, though there are important exceptions.

All plans are required to cover emergency services that you receive out-of-network.  Starting in 2022, it will also be illegal for out-of-network hospitals, doctors, and other providers to bill you more than the in-network cost sharing amount for out-of-network emergency services. If you have concerns that your health plan did not cover out-of-network emergency care appropriately, or that a doctor or hospital billed you too much for out-of-network emergency care, call the Consumer Assistance Program in your state.  A list of Consumer Assistance Programs and contact information can be found here.

The federal government will also establish a national complaints system for consumers.  Check this site for more information as it becomes available:  https://www.cms.gov/nosurprises

In addition, starting in 2022, all plans must cover out-of-network “surprise medical bills.”  These can arise when you are admitted to an in-network hospital, and an out-of-network provider whom you did not pick (such as an anesthesiologist) also takes part in your care.  Health plans are required to cover these surprise out-of-network services, leaving you responsible for only the in-network cost sharing amount.  The out-of-network providers are also prohibited from billing you more than the in-network cost sharing amount.  If you have concerns that your plan did not cover an out-of-network surprise medical bill correctly, or that an out-of-network doctor billed you too much for a surprise medical bill, call the Consumer Assistance Program in your state or contact the national consumer complaints system.

Other than emergency services and surprise medical bills, however, Marketplace plans are not required to cover out-of-network services and most will not.  Most marketplace plans are HMOs and generally require that you get care from in-network providers in order for claims to be covered.

A small number of marketplace plans are so-called PPOs and will provide some coverage for care received from out-of-network.  However, it could be costly to you because the non-network providers don’t have to limit their charges to an amount the insurer says is reasonable, so you might also owe “balance billing” expenses.If you do receive care out of network, it could be costly to you. Generally plans that provide an out-of-network option cover such care at a lower rate (e.g., 80% of in-network costs might be reimbursed but only 60% 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. If there is a Consumer Assistance Program in your state, staff in this program can help you file your appeal.

While we have made every effort to provide accurate information in these FAQs, people should contact the health insurance Marketplace or Medicaid agency in their state for guidance on their specific circumstances.

The Henry J. Kaiser Family Foundation Headquarters: 185 Berry St., Suite 2000, San Francisco, CA 94107 | Phone 650-854-9400
Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270

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Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California.