What You Should Know About Provider Networks

What You Should Know About Provider Insurance companies may have different networks for different plans, so make sure you’re searching the provider network of each specific plan you compare. Networks You can also call the insurance company’s customer service phone number to check if your providers are in the plan’s network. If you travel a lot, check to see if the plan’s network has providers where you might What’s a provider network? need care. A provider network is a list of the doctors, other health Before you apply care providers, and hospitals that a plan contracts with to provide medical care to its members. These Visit HealthCare.gov/see-plans to compare providers are called “network providers” or Marketplace plans and estimated prices before you “in-network providers.” A provider that isn’t contracted enroll. When you compare plans, you can search for with the plan is called an “out-of-network provider.” your doctors and health care facilities. You’ll also be able to check if each plan includes your doctors and How can I see if my doctor is in a facilities in its network. plan’s network before I choose a ® Once you find a plan you like, you can print or email Health Insurance Marketplace plan? the information so you’ll have the full plan name and Make a list of all the providers you use. “Providers” can 14-digit Plan ID when you’re ready to apply through the include doctors, psychologists, or physical therapists, and Marketplace and enroll. health care facilities, like hospitals, urgent care clinics, or pharmacies.

After you submit your application Where can I find the plan type when I’m shopping in the Marketplace? When you apply for coverage through the Marketplace, you can compare plans and prices, and When comparing plans on HealthCare.gov, the plan find out about any savings that may be available to type is listed immediately below its name. Look for help lower your monthly premiums. You can search the initials PPO, POS, HMO, or EPO. The type of plan for specific plans, providers, facilities, or by Plan ID. is also listed on each plan’s “Summary of Benefits Each plan description includes a link to its provider and Coverage.” If you’re not sure what the plan type directory. If you want coverage for dependents, is or you want to know more about the coverage it search for their doctors and facilities too. offers, you can call the health insurance company directly. You can also call the Marketplace Call Center How do different types of plans use at 1-800-318-2596 (TTY: 1-855-889-4325). To find in- provider networks? person assistance in your area, visit LocalHelp.HealthCare.gov. Depending on the type of plan you buy, your plan may cover your care only when you see a network provider. Why do some plans cover benefits and You may have to pay more, and/or get a referral if you services from network providers, but choose to get care from a provider who isn’t in your not out-of-network providers? plan’s network. Types of plans include: Network providers have agreed to offer benefits or Preferred Provider Organizations (PPOs): You pay services to the plan’s members at prices that the n less if you use providers in the plan’s network. For an provider and the plan agreed on. This generally additional cost, you can use doctors, hospitals, and means that they provide a covered benefit at a lower providers outside of the network without a referral. cost to the plan and the plan’s members than to someone without insurance or someone in a plan Point-of-Service (POS) Plans: You pay less if you use where the provider is out-of-network. n doctors, hospitals, and other health care providers that belong to the plan’s network. You’re required to All Marketplace plans must have provider networks get referrals from your primary care doctor to see with enough types of providers to ensure that specialists. their plan members can get plan services without unreasonable delay. Depending on your plan, if you Health Maintenance Organizations (HMOs): use an out-of-network provider, you may have to n You’re usually limited to care from doctors who work pay the full cost of the benefits and services you get for or contract with the HMO and aren’t covered for from that provider, except for emergency services. out-of-network care (except in an emergency). You may be required to live or work in the HMO’s service Insurance plans can’t make you pay more in area to be eligible for coverage. copayments or coinsurance if you get emergency care from an out-of-network hospital. They also can’t Exclusive Provider Organizations (EPOs): You’re make you get prior approval before getting emergency n only covered if you use doctors, specialists, or services from a provider or hospital outside your hospitals in the plan’s network (except in an plan’s network. However, you may have to pay some emergency). out-of-pocket costs, like a deductible, at the in-network rates. Plans aren’t allowed to charge you out-of- network cost-sharing (like out-of-network coinsurance or copayments) for emergency and certain non- emergency services.

What can I do if I enroll in a You can contact your plan to request an exception for Marketplace plan, but my doctor isn’t out-of-network care to be covered like in-network care. in my plan’s network? You may also qualify as a continuing care patient if you’re getting treatment from a provider or facility and If you enroll in a Marketplace plan and find out that your health plan terminates your provider’s contract. your doctor isn’t in the plan’s network, you can switch Contact your plan to see if you qualify for in-network to another plan until the date your coverage starts. Find exceptions or continuity of care. out when your new coverage starts before you cancel your current plan, so you won’t have a gap in coverage. If you go to your doctor and find out later that your If you decide to switch plans, make sure your doctor is new plan doesn’t cover your doctor or doesn’t pay for in your new plan’s provider network. You can find a link the visit, you have the right to appeal the decision and to a list of providers in each plans’ network in the plan have it reviewed by an independent third party. Visit description in your Marketplace account. You can also HealthCare.gov/appeal-insurance-company-decision/ contact your health insurance company to see which appeals/ to learn about the appeals process. doctors, hospitals, and other health care providers are in your plans’ network. After your coverage starts, you won’t be able to change your plan until the next Open Enrollment, unless you get a Special Enrollment Period because you experience certain life events. Qualifying life events include losing health coverage, getting married, moving, or having a baby. Visit HealthCare.gov/reporting-changes if you need to update your application because of a life event. HOW CAN I LEARN MORE? To learn more about coverage through the Marketplace or your benefits and protections, visit HealthCare.gov or call the Marketplace Call Center at 1-800-318-2596. TTY users can call 1-855-889-4325. You have the right to get Marketplace information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit CMS.gov/about-cms/agency-information/aboutwebsite/cmsnondiscriminationnotice, or call the Marketplace Call Center at 1-800-318-2596 for more information. TTY users can call 1-855-889-4325. CMS Product No. 11766 Revised February 2022 This product was produced at U.S. taxpayer expense. ® Health Insurance Marketplace is a registered service mark of the U.S. Department of Health & Human Services.