What is the Difference Between In-Network and Out-of-Network Care Under the ACA?

The Affordable Care Act (ACA) has made significant changes to health insurance, including how in-network and out-of-network care is covered. Here’s an overview of what you need to know:

What is In-Network Care?

In-network care is provided by doctors and hospitals that have contracted with your insurance company. This means that your insurer has negotiated rates for the services they provide. As a result, you typically pay less for in-network care than you would for out-of-network care.

What is Out-of-Network Care?

Out-of-network care is provided by doctors and hospitals that have not contracted with your insurance company. This means that your insurer has not negotiated rates for the services they provide. As a result, you typically pay more for out-of-network care than you would for in-network care.

What the ACA Says About In-Network and Out-of-Network Care

The ACA requires health insurance plans to cover emergency care from both in-network and out-of-network providers. This means that you cannot be denied coverage for emergency care, regardless of whether the provider is in your network.

However, the ACA does not require health insurance plans to cover non-emergency care from out-of-network providers. This means that you may have to pay more for non-emergency care if you see an out-of-network provider.

How to Find In-Network Providers

You can find in-network providers by visiting your insurance company’s website or calling their customer service number. You can also ask your doctor or hospital if they are in your network.

When to Use Out-of-Network Providers

There are a few situations where you may want to use an out-of-network provider:

– If you have a rare condition that requires specialized care.
– If you live in a rural area where there are no in-network providers.
– If you have a trusted relationship with an out-of-network provider.

How to Appeal a Denied Claim

If your insurance company denies a claim for out-of-network care, you have the right to appeal the decision. You can do this by writing a letter to your insurance company and explaining why you believe the claim should be covered.

Conclusion

Understanding the difference between in-network and out-of-network care can help you make informed decisions about your health care. By choosing in-network providers when possible, you can save money on your health care costs.

If you have any questions about in-network and out-of-network care, please contact our licensed agent for help.