Is My Provider In-Network? What If They Aren’t?

Having health insurance is the best way to help keep healthcare costs manageable. When you are signed up for a health insurance plan, you have the peace of knowing that you are covered for many medical services. However, there are some cases when you may not be covered, and you may have to pay for care out of pocket. One example is receiving care from an out-of-network provider. 

What Does Out-Of-Network Mean?

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If you agree to have treatment or services from this provider, then you will have to pay more out of pocket.

A “network” in health insurance speak refers to the healthcare providers whose services are covered by your plan. Health insurance companies make agreements with providers, and these providers then participate in the insurance company’s plan with negotiated rates for services. 

Being “out-of-network  simply means that a doctor, or provider, does not participate, or have a contract, with your insurer. If you agree to have treatment or services from this provider, then you will have to pay more than you would have if you had gone to an in-network provider. Most plans offer some out-of-network coverage. HMO plans, for example, will usually cover out-of-network emergencies. Some plans may also offer limited reimbursement, but generally you should be careful about receiving out-of-network care, as you could end up with a giant bill

What To Do If You Are Not Sure

Always check with your insurance company if you are uncertain whether a specialist or hospital is in-network. In some cases, your primary care physician may send you to a specialist who is out-of-network. If you don’t check ahead of time, then you may be left with a hefty bill after receiving care you assumed you were covered for.

What To Do If You See A Doctor Out-Of-Network

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You can request a network gap exception from your insurance company.

There is something you can do if there is a specific out-of-network specialist that you need to see, or if you are out of town and need to go to a hospital that is not in your network. You can request a network gap exception from your insurance company. This basically means that you are asking your insurer to cover an out-of-network service as if it were in-network. 

If your network gap exception is approved, then you will only have to pay your usual copays and deductible for the out-of-network care you receive. However, you will only be granted one of these exceptions if your insurance company agrees that there is no other way you can get the care you need because their network is too narrow. It is rare for insurance companies to approve these requests because they will end up paying for the extra costs.

If your insurer will not grant you the network gap exception, then you should first find out how much your out-of-network costs will be before you go seek the necessary care. You can then try to negotiate a discount or payment plan with the out-of-network doctor. If you are looking to treat a chronic condition and will need to see a particular specialist that is not in your network, then it might be time to consider another health insurance company or plan. 

Shopping around is your best option to save money on necessary health services. can compare all the available plans within your region, and provide you with quotes within seconds. We will provide you with an agent who will search all the plans and help you find the one that covers any special care you need, for free! This will help you save more money, while still receiving the care you need. To get started, enter your zip code in the bar above, or to speak with an agent directly, call 888-350-1890.

About The Author:
Cassandra Love

With over a decade of helpful content experience Cassandra has dedicated her career to making sure people have access to relevant, easy to understand, and valuable information. After realizing a huge knowledge gap Cassandra spent years researching and working with health insurance companies to create accessible guides and articles to walk anyone through every aspect of the insurance process.

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