Your medical providers and facilities, like hospitals, routinely negotiate and sign contracts with your health insurer. Most of the time, these negotiations are resolved without disrupting your coverage.
These agreements between providers and insurers determine how much doctors and hospitals are paid for providing covered services. They also categorize which doctors and facilities are in-network and which ones are out-of-network, which ultimately affects how much you pay for health care.
In-network means you're getting services from medical providers, hospitals, and other 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.
If you recently received a letter telling you that your doctor or hospital may leave your insurer's network due to a contract termination, here's what it means and what you need to know to avoid unexpected costs.
Why contract negotiations happen
Groups of health care providers and facilities, called medical provider networks, regularly review their agreements with health insurance companies. If they can't agree on what the insurer pays the providers for covered services, the providers may choose to leave the insurer's network.
We know it can be frustrating when your provider and your health insurance company can’t immediately agree on a contract. These agreements are worked out directly between the companies. While we don’t have the authority to set prices and terms to make them reach a deal, we do keep an eye on the process. Our role is to make sure they follow state laws and rules, give you proper notice, and ensure your health plan still has enough in‑network providers to meet your needs.
What it means for you when a contract is ending
When you get a notice in the mail that the contract between your provider and health insurance company is ending, it raises questions about what your care will cost. Here's what to know and what you can do as negotiations play out.
During contract negotiations
While your insurer and the medical provider or hospital are in contract negotiations, it's a good idea to check your health plan's:
- Out-of-network benefits (PPOs often have out-of-network benefits; HMOs usually don't)
- Other in-network providers available in your area on your insurer's website
- Qualifications for continuity of care
Your continuity of care protections
Even if the contract between your health insurer and providers ends, you have two safety nets — called continuity of care — under Washington state law and the federal No Surprises Act.
You can receive services from your primary care provider at the in-network price for up to 60 days after you're notified that their contract is ending. You may also have the right to keep your provider for an additional 90-days after the contract ends at in-network rates 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
If you think you qualify for the 90-day continuity of care protection, visit your insurer's website or call their member services number on the back of your insurance card and ask, "If this provider leaves my network, what is the process for me to request continuity of care?"
If your provider goes out of network
If negotiations fail and your provider and insurer can't reach an agreement, your costs will change. Out-of-network care is more expensive, and some health plans don't cover out-of-network care at all, which means you'll have to pay the whole bill. Some providers may offer discounts, but you'll have to ask them directly.
Another thing to be aware of is balance billing. Because out‑of‑network providers aren’t tied to your health plan’s prices, they can bill you for anything the plan doesn’t cover. That can lead to big, unexpected bills. In‑network providers aren’t allowed to do this because their prices are already set in advance.
Emergency services coverage
If your provider leaves your health plan’s network after contract negotiations fall through, your emergency care, substance use crisis services, and mental health crisis services are still protected from balance billing.
You can go to the nearest emergency room, call 911, or call 988 for a mental health or substance use disorder crisis, and your insurer must treat the care you receive as in‑network. That means you’ll pay your normal in‑network costs and won't get a surprise bill for the difference between what your provider charges and what your insurance company pays the provider.
What's in the contract termination and expiration notices
Insurers, medical providers, and hospitals regularly update and negotiate their contracts. Washington state law requires that if an insurer, medical provider, or hospital is within 45-days of a contract potentially ending, they must notify enrollees and patients about the possibility of a contract not being reached. When they send you a notice as a health plan enrollee or patient, it must include:
- Which providers and facilities will be out-of-network if the insurer and provider network can't reach an agreement
- Guidance on appointments you scheduled beyond the contract termination date
- An explanation of your continuity of care rights to continue seeing your provider under state law and the federal No Surprises Act
To protect consumers from unnecessary disruption and keep them out of contract disputes, Washington state law, RCW 48.43.732, says insurers and providers can’t send notices until it's within 45 days of the contract ending.