What you need to know about medical provider networks

What is a medical provider network?

A network is a group of medical providers, such as doctors, hospitals, labs, therapists, etc., that contract with a health plan to provide services to its members at negotiated rates. Provider networks allow health plans to control costs and provide protection to consumers against overbilling or other billing issues.

What networks should include

Health plan networks must meet state law (leg.wa.gov). This means they must:

  • Include certain types of providers, such as women’s health care practitioners, tribal and rural health care services and centers, primary care doctors, and mental health providers.
  • Have sufficient numbers of each type of provider to meet anticipated consumer needs.
  • Provide 24-hour emergency care.

If you’re having trouble receiving services from your health plan, file a complaint with our office. We can follow up with the company to make sure you can access the care you’ve paid for.

NOTE: We don't have the authority to order health plans to include a specific doctor or medical facility.

Risks of using an out-of-network provider

If you see a medical provider who's not in your health plan’s network (a group of doctors, hospitals and other health care providers), you might pay significantly more. Here are some things to consider:

  • An out-of-network medical provider can bill you for 100 percent of the difference between what they charge and what the health plan pays. This is called “balance billing.” It can leave you with an unexpected and large bill. In-network providers can’t do this.
  • Some health plans don’t apply the coinsurance you pay for out-of-network services to the out-of-pocket limit. You might have to pay unlimited amounts of coinsurance for out-of-network services.
  • Some health plans don’t cover out-of-network services at all.
  • If you have an emergency, your health plan must cover costs at the in-network level until you're medically stable - even if you need to go to an out-of-network hospital. However, emergency room providers and hospitals can balance bill you for the charges your insurance doesn't cover.
  • Out-of-network medical providers don't have to bill the health plan, so you may need to do it.

What to do before you choose a health plan

Before you enroll in a health plan, confirm with both your health plan and medical provider(s) that they’re part of your plan’s network. Networks change, so you should also periodically confirm your provider’s network status even after you’ve enrolled in the plan.

Be aware that health plans sold inside the Washington Health Benefit Exchange (wahealthplanfinder.org) may offer different provider networks than those sold outside the Exchange.

Questions you should ask

Your health plan:

  • Does the health plan use provider networks?
  • Does it cover services if you 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 you pay for out-of-network services?

Your medical provider:

  • How do you collect your deductible, copay and coinsurance from me?
  • How do you bill for services?
  • Are the labs in-network?

See also

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