When Out-of-Network Care Can be Covered In Network
Summary
Receiving care from a provider in your health plan’s network usually costs you much less than going to an out-of-network provider. (See In-Network and Out-of-Network Care). But, you may need to go out of network for certain types of care, especially if you or a member of your family has a rare illness, such as a genetic disorder. Suppose no provider in your network has the training or experience to treat it the right way. With prior approval from your insurer, you may be able to receive the care you need out-of-network and still pay only the lower, in-network rate.
Different insurers take different approaches to requests for out-of-network care at in-network rates. You may have to make a formal request to your insurer, sometimes called an “appeal,” or send in a request for prior authorization. Information about the process to follow should be available from your insurer’s website, plan documents or customer service representative.
Your primary care physician (PCP) or in-network specialist typically send the initial request to the insurer. The insurer may deny your first request. But, usually you have more than one chance to get your case reviewed. You may appeal the decision “internally,” which means you can ask the insurer to reconsider your benefits denial. If your request is still denied, federal or state law may require your insurer to allow you to start an “external” appeal. That means you appeal to an independent, outside group.
If your insurer agrees to let you go out of network at the in-network rate, your out-of-network referral will usually be to a specific doctor. But, typically, any doctor managing your care will work with other providers who perform related procedures. The claim from the original doctor will be processed at the in-network rate. But, the claims from the other providers may be processed as out of network and you will have to appeal the insurer’s decision. To avoid that, it’s best that you work out those details with the insurer in advance.
Situations When You May Need Care from an Out-of-Network Provider
There may be several situations when you may need out-of-network care and can get it at the in-network rate. These situations may depend on your plan, or on the laws in your state. For example:
- You have a rare, serious sickness or health problem, such as a genetic disorder. You may have to leave your network to find a provider who is qualified to treat the rare condition.
- You live in a remote area where the network is not adequate to treat your serious condition.
- You have an emergency, when you need care right away for a serious sickness or injury. You may need to go to the nearest emergency room, even if it is not in your network. (See Emergency Care and Urgent Care.)
- You are already being treated by an in-network doctor for a serious condition. Then, you switch to a new health plan and that doctor is not in the new plan’s network. Or your plan stays the same, but the doctor leaves the network. You may be able to keep seeing the doctor at the in-network rate for the duration of the treatment.
- Natural disasters can force you to evacuate to places where you need care outside your network. If the state or federal government declares a state of emergency, you may qualify for in-network rates.
- If your child moves away to college and you want him or her to be able to see doctors close to the college, your plan may offer a guest membership. That would allow your child to be a “guest” of a network of doctors in that area. Similarly, some plans have “travel” networks to cover you when on business trips or vacations.
Many states have laws requiring plans to cover such out-of-network services at in-network rates. If you need to go out of network, check with your insurer and follow the rules that pertain to your state and plan.
Your Action Plan: Ask for In-Network Coverage for Your Out-of-Network Care
Do you need to go out of network? If so, follow these steps to request coverage at the in-network rate.
- Do your own research to find out what care you need and from whom.
- Talk to your PCP and to your in-network specialist. Tell them what you have learned in your research. Ask them if they can support you with medical documentation.
- Request that your insurer cover you at the in-network rate before you go out of network. If you wait until afterward, you may face big bills and an even harder challenge.
- If your medical need is urgent, ask for an expedited appeals process.
- If your request is approved, ask for a case manager to handle your out-of-network claims.
- Look at your Explanations of Benefits (EOBs) carefully. Make sure your cost sharing is at the in-network rate, not the out-of-network rate.
- Know how long your out-of-network referral is good for. Make sure it covers follow-up care.
- If your request is denied, talk to your out-of-network doctor. Get an estimate of how much the services are going to cost. Use the FH Medical Cost Lookup tool or the FH Dental Cost Lookup tool to see what those services typically cost in that geographic area. See if you can pay at a discounted rate.
Most important, understand you have choices. Don’t feel obligated to use an in-network provider that you feel is unfit for your needs. You are your own best advocate. If your network can’t give you the care you need, look for out-of-network solutions—and follow all of the steps listed here to have your insurer cover your care at the in-network rate.