However, under certain circumstances, your health plan will pay for out-of-network care at the same rate it pays for in-network care, saving you a lot of money. You just have to know when and how to ask.
This article will explain what you should expect in terms of out-of-network care, and how you might be able to get in-network rates even if you need to go outside your health plan’s network.
When Your Health Plan Will Pay In-Network Rates for Out-of-Network Care
Health insurance is regulated by state laws. Each state differs from its neighbors, so what follows are general guidelines that apply to most of the country. However, if your state laws vary, your health plan may follow slightly different rules.
Health plans may consider paying for care you get out-of-network as though you got it from an in-network provider in the following circumstances:
Emergency Situations
If it was an emergency and you went to the nearest emergency room capable of treating your condition, your insurance will likely cover the treatment as if it had been in-network.
Under the Affordable Care Act, which applies nationwide, insurers are required to cover out-of-network emergency care as if it was in-network care, which means your deductible and coinsurance can’t be higher than the regular in-network amounts.
Prior to 2022, however, the hospital and emergency room medical providers could still send you a balance bill for the difference between what they charged and what your insurer paid (over and above the deductible and coinsurance amounts you paid).
But this changed for health plans years that started on or after January 1, 2022. New federal rules prevent balance billing in emergency situations, as well as situations in which the patient goes to an in-network facility but is treated there by one or more medical providers who aren’t in the patient’s insurance network.
As a general rule, keep in mind that just because a particular service is provided at the emergency room does not mean that the situation was indeed an emergency. Your health plan is likely to balk at an “emergency” like an earache, a nagging cough, or a single episode of vomiting.
But your plan should cover out-of-network emergency care for things like suspected heart attacks, strokes, or life-threatening and limb-threatening injuries. The “prudent layperson standard” addresses the fact that most people are not medical professionals, and have to make judgment calls about when to use emergency services. If a prudent layperson would consider it an emergency, then health plans should also consider it an emergency—even if the eventual diagnosis ends up being less urgent than the patient initially feared.
No In-Network Providers Are Available
If there are no in-network providers where you are, your insurance may cover your treatment as if it had been in-network, even if you have to use an out-of-network provider.
This may mean you’re out of town when you get sick and discover your health plan’s network doesn’t cover the city you’re visiting. Note that for most plans, this would require that the situation be an emergency. You generally can’t receive in-network coverage when you’re traveling in an area where your plan doesn’t have a provider network unless it’s an emergency.
It could also mean you’re within your health plan’s regular territory, but your health plan’s network doesn’t include the type of specialist you need, or the only in-network specialist is 200 miles away. In both cases, your health plan will be more likely to cover out-of-network care at an in-network rate if you contact the health plan before you get the care and explain the situation (in non-emergency situations, this should always be your approach).
Your Provider Changes Status in the Middle of Complex Treatment
If you are in the middle of a complex treatment cycle (think chemotherapy or organ transplant) when your provider suddenly goes from being in-network to out-of-network, your insurer may temporarily continue to cover your care as if it were in-network.
This might happen because your provider was dropped from, or chose to leave, the network. It might also happen because your health insurance coverage changed. For example, perhaps you have job-based coverage and your employer no longer offered the plan you’d had for years so you were forced to switch to a new plan.
In some cases, your current health plan will allow you to complete your treatment cycle with the out-of-network provider while covering that care at the in-network rate. This is usually referred to as “transition of care” or “continuity of care.”
You’ll need to discuss this with your insurer soon after enrolling in the plan, and if the transitional period is approved, it will be for a temporary period of time—a transition of care allowance won’t give you indefinite in-network coverage for an out-of-network provider. Here are examples of how this works with Cigna and UnitedHealthcare.
The new federal rules that prevent surprise balance billing in emergency situations (described above) also require insurers to provide up to 90 days of transitional coverage when a provider leaves the network and a patient is in the middle of an ongoing treatment situation. This applies to plan years that start in 2022 or later, ensuring that people have access to temporary in-network coverage when it would otherwise end after a provider leaves the insurer’s network.
Natural Disaster
If a natural disaster makes it nearly impossible for you to get in-network care, your insurer may pay for out-of-network care as if it were in-network.
If your area just went through a flood, hurricane, earthquake, or wildfire that severely impacted the in-network facilities in your area, your health plan may be willing to cover your out-of-network care at in-network rates because the in-network facilities can’t care for you.
How to Get Your Health Plan to Cover Out-of-Network Care at In-Network Rates
With the exception of emergency care, you’ll need to make a convincing argument to your health plan about why you need out-of-network care and why using an in-network provider won’t work.
You’ll have a better chance of success if you plan in advance. If this is non-emergency care, approach your health plan with this request well before you plan to get the out-of-network care. This process may take weeks.
Do your homework so you can bolster your argument with facts, not just opinions. Enlist the aid of your in-network primary care physician to write a letter to your health plan or speak with your health plan’s medical director about why your request should be honored. Money talks, so if you can show how using an out-of-network provider might save your health insurance company money in the long run, that will help your cause.
When you’re interacting with your health plan, maintain a professional, polite demeanor. Be assertive, but not rude. If you’re having a phone conversation, get the name and title of the person you’re speaking with. Write everything down. After phone conversations, consider writing a letter or email summarizing the phone conversation and sending it to the person you spoke with, or to his or her supervisor, as a reminder of the details of the conversation. Get any agreements in writing.
When negotiating for out-of-network coverage at in-network rates, there are at least two things to negotiate: cost-sharing and the reasonable and customary fee.
Cost-sharing negotiations: When getting out-of-network care through a PPO or POS plan, you will likely have a higher deductible for out-of-network care than for in-network care. Money you previously paid toward your in-network deductible will generally not count toward the out-of-network deductible, so you could be starting all over at zero. Additionally, the coinsurance for out-of-network care is usually significantly higher than for in-network care. Try to negotiate for the care to be paid for using the in-network deductible rate and the in-network coinsurance rate, exactly as though you were using an in-network provider. Reasonable and customary fee/balance billing: When using an out-of-network provider, you’re at risk for being balance billed which can lead to paying a much larger percentage of the bill than you had predicted. Health insurers will look at an out-of-network bill for, say, $15,000 and say something to the effect of “This charge is way too high for that service. The bill is unreasonable. The more usual and customary charge for that service is $10,000, so we’ll pay our share of $10,000. ” Unfortunately, you may get stuck paying the $5,000 difference in addition to your cost-sharing. This is because the provider isn’t obligated to accept your health plan’s reasonable and customary rate, since they don’t have a contract with your health plan. (Note that if it’s an emergency or the out-of-network provider performs the services at an in-network hospital, the No Surprises Act protects you from balance billing. )
When negotiating for out-of-network care at in-network rates, be sure to address the difference between what your out-of-network provider charges and what your health plan thinks is reasonable. This may involve your health plan drawing up a contract with your out-of-network provider for a single episode of care at a specific negotiated rate.
Try to ensure that the contract has a “no balance billing” clause so you won’t get stuck with any costs other than the deductible, copay, and coinsurance. But know that the out-of-network provider may simply refuse to agree to something like that, and there isn’t really any way to force them to do so.
As noted above, this is no longer the case as of 2022 for emergency care and situations in which an out-of-network provider works at an in-network facility. But in other situations that involve out-of-network care, the providers can balance bill for the difference between what they billed and what the insurer considers reasonable.
This is something you’ll want to discuss with the medical provider in advance, even if you’ve already got the insurer to agree to provide in-network coverage. You don’t want to be surprised after the fact when you get a bill from the provider (for more than just your deductible, coinsurance, etc) 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-network medical providers. Others will cover out-of-network care, but with higher cost-sharing (deductible, copays, coinsurance) than in-network care.
Health plans are required to cover emergency care as if it’s in-network, regardless of whether it is or not (and as of 2022, the patient cannot be balance billed by an out-of-network emergency provider). But there are other circumstances in which a health plan may be willing to cover out-of-network care as if it’s in-network. And out-of-network medical providers will sometimes agree to a one-time contract under which they won’t balance bill the patient in that situation.
A Word From Verywell
Using in-network medical providers is generally your best bet in terms of keeping things simple with your health benefits. But that’s not always possible or optimal. If you find yourself in a situation where only an out-of-network provider will work, you can address this with your health plan and the medical provider. You may find that you’re able to negotiate a deal, but you won’t know unless you ask.
