Provider networks include doctors, hospitals, labs, therapists, and more. Provider networks help you pay less, avoid billing issues, and ensure you can use covered services promised in your health plan without getting a surprise bill.
What networks should include
Under state law, health plan networks must meet certain access requirements. This is usually called "network adequacy" or meeting "network access standards." Network adequacy means the plan must:
- Include certain types of providers, such as those for women’s health care, tribal and rural health care, primary care, and mental health care.
- Have enough providers to help the number of patients they expect.
- Provide 24-hour emergency care.
- Allow you to access all health plan services in a timely manner.
Note: We can't force health plans to include a specific doctor or medical facility.
In-network vs. out-of-network care
Understanding your health plan's network helps avoid unplanned expenses for out-of-network care.
In-network means you're getting services from medical providers, hospitals, and services that have agreements with your health plan for lower negotiated costs.
Out-of-network means you're getting services from a medical provider or facility that doesn't have an agreement with your health plan and isn't in your health plan's provider network.
Risks of using an out-of-network provider
If you see a medical provider who's not in your health plan’s network, you might pay a lot more. Here are some things to consider:
- Some health plans don’t cover out-of-network services at all. You will be responsible for the full bill.
- Some health plans don’t apply the coinsurance you pay for out-of-network services to your out-of-pocket limit. Even if you reach that limit, you might still have to pay coinsurance for out-of-network services.
- Out-of-network providers can charge you for everything your health plan doesn't pay for. This is called “balance billing.” It can leave you with a large, unexpected bill. In-network providers can’t do this.
- Out-of-network providers don't have to bill the health plan. You will be required to pay for the full cost of the service and may need to ask your insurer to reimburse you.
Understand your plan type and its limitations
| Network type | Will the plan cover out-of-network care? | Do you need a referral from a primary care doctor to see a specialist? |
|---|---|---|
| Preferred Provider Organization (PPO) | Yes* | No |
| Point of Service (POS) | Yes* | Usually |
| Exclusive Provider Organization (EPO) | No (emergency only) | No |
| Health Maintenance Organization (HMO) | No (emergency only) | Usually |
*Using an out-of-network provider for care generally requires you to pay a higher deductible, copay, or coinsurance.
If you have trouble accessing your health plan services
If you're having trouble finding an in-network provider or there's a long delay in getting an appointment, call your health insurer. If they can't find an in-network provider for you, they must help you find an out-of-network provider and cover it as if it's in-network.
If you're still having issues, file a complaint with us.
What happens when your provider leaves your health plan network
If your in-network provider leaves the network, you may have the right to keep the provider at the in-network rate for up to 90 days if you are:
- Seeing the provider for a serious or complex condition, including certain chronic conditions.
- Undergoing a course of institutional or inpatient care from the provider.
- Being scheduled for non-elective surgery by the provider.
- Pregnant and seeing the provider for pregnancy-related care.
- Determined to be terminally ill.
You can receive services from your primary care provider at the in-network price for up to 60 days after you get notified that their contract is ending.
Your rights as a consumer
Some of the protections you have as a consumer include:
- Your right to appeal any claim your health plan denies.
- Protection from unexpected medical billing for certain out-of-network care through the Balance Billing Protection Act and the federal No Surprises Act.
- Your insurer must notify you if your in-network provider is leaving the health plan network.
What to do before you choose a health plan
Confirm with both your health plan and medical providers that they’re part of your plan’s network. Networks change, so you should also regularly ask your provider whether they're still part of your plan's network.
Individual health plans on the Washington Health Benefit Exchange may have different provider networks than plans you buy directly from an insurer.
Good questions to ask your health plan and providers
Your health plan:
- Does it cover services if I see an out-of-network provider?
- Is there a separate deductible or higher coinsurance for out-of-network services?
- Is there an out-of-pocket limit for coinsurance I pay for out-of-network services?
- Where can I find a list of in-network providers?
Your medical provider:
- How do you collect my deductible, copay, and coinsurance?
- How do you bill for services?
- Which labs does the medical provider use, and are they in-network?