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 and apply in-network cost-sharing.  In addition, it is now illegal for out-of-network hospitals, doctors, and other providers (other than ground ambulance) to bill you more than the in-network cost sharing amount for out-of-network emergency services.  Instead, they are required to submit claims directly to your health plan, find out the amount of in-network cost sharing you owe, and bill you for no more than that amount.

In addition, all plans must now cover out-of-network “surprise bills” for non-emergency services that you receive while you are at an in-network hospital or other facility, and apply in-network cost-sharing.  These so-called surprise medical bills can arise when an out-of-network provider whom you did not pick (such as an anesthesiologist) also takes part in your care.

These out-of-network providers also must submit claims directly to your insurance and are prohibited from billing you more than the in-network cost-sharing amount.

If you have concerns that your health plan did not correctly cover an out-of-network surprise medical bill, or that an out-of-network doctor billed you too much for a surprise medical bill, call the Consumer Assistance Program in your state.  A list of Consumer Assistance Programs and contact information can be found here.  You can also file a complaint at the national complaints system for surprise medical bills at https://www.cms.gov/nosurprises

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 out-of-network.  However, it could be costly to you because your plan will probably cover less of the bill than it would for in-network services.  In addition, 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 (the difference between what your plan pays and the provider’s full charge.)

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 – and if your plan denies coverage, 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.