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What happens if I have to get care from an off-network health insurance provider?

Plans offered through the exchange are not required to cover any kind of care received from an off-network provider, though many will provide at least some level of coverage for off-network care. However, it is still better to get care from on-network providers whenever possible. In addition to not providing as much coverage for off-network care, insurers may also apply a separate deductible, and the payments made for that care may not count towards your annual out-of-pocket maximum. The providers themselves also aren’t subject to cost limitations imposed by the insurer, so they may charge you more for the care than they would have if they had been part of the plan’s network.

In some cases, you may be able to make an appeal to the insurer to not charge you extra for off-network services. For example, if you went outside the network because none of the on-network providers would be able to perform the necessary procedure, or if you were unaware that some of the providers involved in your treatment were not on your network, you may be able to have the extra charges removed. If you want to make an appeal, check to see whether your state has a Consumer Assistance Program. If so, they can help you file your appeal.

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