Provider networks include doctors, hospitals, labs, therapists and more. Provider networks help you pay less and avoid billing issues.
What networks should include
Under state law, health plan networks must meet certain access requirements. This means they must:
- Include certain types of providers, such as those for women’s health care, tribal and rural health care, primary care and mental health care.
- Have enough providers to help the number of patients they expect.
- Provide 24-hour emergency care.
If you’re having trouble accessing your health plan's services, file a complaint with us. We can contact the company to make sure you can get the care you’ve paid for.
Note: We can't force 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, you might pay a lot more. Here are some things to consider:
- Out-of-network providers can charge you for everything your health plan doesn't pay for. This is called “balance billing.” It can leave you with a large, unexpected bill. In-network providers can’t do this.
- Some health plans don’t apply the coinsurance you pay for out-of-network services to your out-of-pocket limit. Even if you reach that limit, you might still have to pay 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.
- Out-of-network providers don't have to bill the health plan. You may need to ask your insurer to pay you back.
What to do before you choose a health plan
Confirm with both your health plan and medical providers that they’re part of your plan’s network. Networks change, so you should also regularly ask your provider to whether they're still part of your plan's network.
Individual health plans on the Washington Health Benefit Exchange may have different provider networks than plans you buy directly from an insurer.
Good questions to ask your health plan and providers
Your health plan:
- Does the health plan use provider networks?
- Does it cover services if I 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 I pay for out-of-network services?
Your medical provider:
- How do you collect my deductible, copay and coinsurance?
- How do you bill for services?
- Are the labs in-network?