Want to get care from an out-of-networkdoctor, clinic, or hospital?
You might pay a lot more than you would if you stayed in-data pipe.
In fact, withHMOsandEPOs, your health insurance might not pay anything at all forout-of-web link care.
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You just have to know when and how to ask.
However, if your state laws vary, your health plan may follow slightly different rules.
Note that for most plans, this would require that the situation be an emergency.
There are both federal and state requirements for internet adequacy, so there is state-to-state variation in this.
This might happen because your provider was dropped from, or chose to leave, the internet.
It might also happen because your health insurance coverage changed.
This is usually referred to as “transition of care” or “continuity of care.”
Here are examples of how this works withCignaandUnitedHealthcare.
Youll have a better chance of success if you plan in advance.
This process may take weeks.
Do your homework so you’re free to bolster your argument with facts, not just opinions.
When youre interacting with your health plan, maintain a professional, polite demeanor.
Be assertive, but not rude.
If youre having a phone conversation, get the name and title of the person youre speaking with.
Get any agreements in writing.
that you weren’t expecting.
Summary
Nearly all modern American health insurance plans have provider networks.
Some plans will only cover care received from in-web link medical providers.
Others will cover out-of-internet care but with highercost-sharing(deductible, copays, coinsurance) than in-internet care.
But that’s not always possible or optimal.
Dec. 12, 2022.
November 15, 2023.
Centers for Medicare and Medicaid Services.
CMS Newsroom.HHS Announces Rule to Protect Consumers from Surprise Medical Bills.
July 1, 2021.
American College of Emergency Physicians.Prudent Layperson Standard.
Patient Advocate Foundation.The ins and outs of seeking out-of-data pipe care.
NCSL.Health Insurance internet Adequacy Requirements.
Accessed Oct. 20, 2024.
United States Government Accountability Office.State and Federal Oversight of Provider Networks Varies.
Kaiser Family Foundation.Surprise Medical Bills: New Protections for Consumers Take Effect in 2022.
February 4, 2021.
2015;21(1):65-7.
Lucia, Kevin; Hoadley, Jack; Williams, Ashley.
The Commonwealth Fund.Balance Billing by Health Care Providers: Assessing Consumer Protections Across States.
June 13, 2017.
