Understanding Your ACA Health Insurance: Navigating Out-of-Network Coverage

In the healthcare industry, it’s common for patients to encounter situations where their desired providers are not within their insurance network. This can be frustrating, especially for individuals seeking specialized treatments like Dialectical Behavior Therapy (DBT). But don’t fret; the Affordable Care Act (ACA) provides options to protect consumers’ access to necessary medical care.

In-Network vs. Out-of-Network Providers

Health insurance networks consist of healthcare providers who have contracted with insurance companies to provide services at specific rates. When you receive care within your network, you typically pay lower out-of-pocket costs, such as copays or coinsurance. However, if you choose to see a provider who is not in your network, you may face higher expenses.

Network Adequacy Exceptions

The ACA requires insurance companies to maintain adequate networks of healthcare providers. If you are unable to find an in-network provider for a necessary medical service, you may request a Network Adequacy Exception (NAE). The insurance company will review your request and, upon approval, allow you to receive care from an out-of-network provider.

Billing for Out-of-Network Services

When you receive services from an out-of-network provider, you will typically pay the provider directly. You can then submit a claim to your insurance company for reimbursement. The provider will bill the insurance company at their usual and customary rate (UCR).

However, the insurance company may not reimburse you the full UCR amount. Instead, they may apply their own allowed amount, which is often lower than the UCR. This means you may be responsible for the difference between the provider’s charge and the allowed amount.

Balance Billing Protection

In some cases, the provider may charge you the full UCR amount, even though your insurance company has a lower allowed amount. This is known as balance billing. However, under the ACA, you are protected from balance billing if you have:

A Network Adequacy Exception
Emergency services
Services that are not available within a reasonable distance of your home

Steps to Take

If you need to see an out-of-network provider, here are the steps you should take:

1. Request a Network Adequacy Exception from your insurance company.
2. Find an out-of-network provider who is willing to accept the insurance company’s allowed amount.
3. Submit a claim to your insurance company for reimbursement.
4. Review the reimbursement amount and communicate with your provider and insurance company as needed.

Contacting a Licensed Health Insurance Agent

Navigating the complexities of health insurance can be challenging. If you have any questions or concerns about your coverage, don’t hesitate to contact a licensed health insurance agent. They can provide personalized assistance tailored to your specific needs.