How to Choose a Doctor?
Each health plan will have their own separate contracts with providers. It’s important for you to understand how their networks operate and the restrictions and limitations for each one.
- Health Maintenance Organizations (HMOs): You're usually limited to care from doctors who work for or contract with the HMO and aren't covered for out-of-network care (except in an emergency). You may be required to live or work in the HMO's service area to be eligible for coverage.
- Preferred Provider Organizations (PPOs): You pay less if you use providers in the plan’s network. For an additional cost, you can use doctors, hospitals, and providers outside of the network without a referral.
- Exclusive Provider Organizations (EPOs): You’re only covered if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency).
- Point
of Service (POS) Plans: You pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. You’re required to get referrals from your primary care doctor to see specialists.
Why do some plans cover benefits and services from network providers, but not out-of-network providers?
Network providers have agreed to offer benefits or services to the plan’s members at prices that the provider and the plan agreed on. This generally means that they provide a covered benefit at a lower cost to the plan and the plan’s members than to someone without insurance or someone in a plan where the provider is out of network.
All Marketplace plans must have provider networks with enough types of providers to ensure that their plan members can get plan services without unreasonable delay. Depending on your plan, if you use an out of network provider, you may have to pay the full cost of the benefits and services you get from that provider, except for emergency services.
Insurance plans can’t make you pay more in copayments or coinsurance if you get emergency care from an out of network hospital. They also can’t make you get prior approval before getting emergency services from a provider or hospital outside your plan’s network. However, you may have to pay some 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 nonemergency services.
What can I do if I enroll in a Marketplace plan, but my doctor isn't in my plan's network?
If you enroll in a Marketplace plan and find out that your doctor isn’t in the plan’s network, you can switch to another plan until the date your coverage starts. Find out when your new coverage starts before you cancel your current plan, so you won’t have a gap in coverage. If you decide to switch plans, make sure your doctor is in your new plan’s provider network. You can find a link to a list of providers in each plans’ network in the plan description in your Marketplace account. You can also contact your health insurance company to see which 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.
You can contact your plan to request an exception for out of network care to be covered like in network care. You may also qualify as a continuing care patient if you’re getting treatment from a provider or facility and your health plan terminates your provider’s contract. Contact your plan to see if you qualify for in network exceptions or continuity of care.
If you go to your doctor and find out later that your new plan doesn’t cover your doctor or doesn’t pay for the visit, you have the right to appeal the decision and have it reviewed by an independent third party. Visit HealthCare.gov/appeal insurance company decision/ appeals/ to learn about the appeals process.
