Your rights to see out-of-network providers

The Office of the Insurance Commissioner reviews health plans to make sure that consumers have reasonable access to and choice among medical providers and facilities, within a reasonable distance, for all covered benefits.

We also ensure that all qualified health plans offered through the Washington Healthplanfinder meet the new health reform requirements.

In most cases, health plans deliver their benefits by contracting with in-network providers at negotiated rates. In some cases, such as where unique covered services are available only through a particular provider or facility, plans may make other arrangements (such as paying billed charges) to ensure access to these services.

If these types of arrangements are necessary to receive care, patients will pay the same share of costs as they would at any other in-network facility.

Questions and answers

Can the insurance commissioner require plans to include certain providers or medical facilities in health plans?

No. The insurance commissioner's office must ensure that qualified health plans include certain types of providers with a historical commitment to underserved populations. Beyond that, we have no authority to order an insurance company to include a specific doctor or medical facility in a health plan. Insurance companies and health care providers privately negotiate the agreements and reimbursement rates for their provider networks.

Even though Seattle Children’s is not included in the provider networks of some health plans, can individuals still get services there?

Seattle Children’s provides some unique pediatric health care treatments and services that other medical facilities in Washington do not. Three of the insurance companies that offer plans in the Washington Healthplanfinder (Premera, Bridgespan, and Coordinated Care) do not include Seattle Children’s in their provider networks.

However, all three health insurers have assured us that consumers enrolled in their plans will have access to any unique services that Seattle Children’s provides, at no greater cost than if they were a network provider. If consumers want other non-unique services from Seattle Children’s, they will be charged the out-of-network price (the amount should be detailed in the health plan's benefit booklet).

What if there is an emergency and the closest hospital is out-of-network?

State law protects consumers from unexpected costs if they need to go to an out-of-network facility for emergency care.

If a consumer reasonably believes that going to an in-network hospital ER would have resulted in a delay that would worsen the emergency, their health plan must pay the same amount to the out of network ER provider as they would to a contracted provider. However, consumers need to be aware that out of network emergency rooms can bill them for any amounts they charge over the contracted rate paid by their insurance company.

Remember, most health plans require an enrollee to contact the plan as soon as possible if the emergency care results in inpatient treatment (usually within 24 hours of admission).

What is the insurance commissioner doing to improve access for consumers?

We have adopted a new rule designed to improve provider network access.

The rule sets specific requirements for provider networks that a health insurer must have in place to ensure access to covered services. These include:

  • Having an adequate number of providers and sufficient types of providers to support delivery of and access to covered services without unreasonable delay
  • Providing access to care in a timely manner and within reasonable proximity
  • Improving transparency so that consumers understand how to access in-network and out-of-network care

Health plans are allowed to offer narrower provider networks, since some consumers may wish to select a less expensive plan in exchange for fewer choices in providers. But, these narrower network plans must still ensure access to covered services.

What can consumers do if they have current issues about getting care from specific providers?

If consumers have complaints about how to access care at a provider or facility, such as Seattle Children's, we will investigate.

Our consumer advocates are available by phone at 1-800-562-6900, Monday through Friday from 8 a.m. - 5 p.m.

Complaints also can be filed online, 24 hours a day, seven days a week, by the family or parent, a friend of the family or even their medical provider.

 

Updated 04/28/2014

See also

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