Will Insurance Companies Pay for Out-of-Network Care?
Virtually every insurance company has a list of in-network providers. A provider is a person or facility that provides healthcare. When a provider is listed as “in-network,” there is generally some type of contractual agreement between the provider and the health insurer regarding the cost of services. The provider will generally accept negotiated rates (AKA allowable amounts) from the insurance company or its affiliates for specific services, which means the patient will typically pay less for medical services and treatments than for providers who are not in-network.
Healthcare providers who do not participate in your health plan’s network are considered out-of-network. These providers have no contract with the health insurer to accept negotiated rates. Your insurance company will often either not pay anything to an out-of-network provider or will pay much less than they would to an in-network provider, leaving you with a larger portion of the cost.
Ensuring your chosen healthcare provider is in-network with your insurer can significantly reduce your medical expenses. When you see an in-network provider, your copays will generally be applied to your in network deductible and out-of-pocket maximum, while the costs of seeing an out-of-network provider will not likely be applied to your in-network deductible and out-of-pocket maximum. (In fact, health insurance companies typically have separate deductibles for in-network and out-of-network providers.) But what happens if you need a medical procedure or a special type of doctor and you cannot find one in-network?
Or what if your general practitioner wants to refer you to “one of the best” specialists, but he or she is out-of-network? If you find yourself in one of these situations, it can be extremely beneficial for you to speak to an experienced insurance denial attorney from the Law Offices of Scott Glovsky. We can help you determine whether your insurance company can be forced to pay for out-of-network costs and, if so, what the process is.
What is a Network Gap Exception?
A network gap exception may also be known as an out-of-network exception, a gap waiver, a network insufficiency exception, or a clinical gap exception. Network gap exceptions are used by insurance companies to compensate for specific gaps in their network of contracted healthcare providers, allowing you to obtain healthcare from an out-of-network provider while paying lower fees than you otherwise would.
Insurers are less likely to pay out-of-network costs if you have an EPO or HMO plan as these plans generally do not provide out-of-network options. If your plan is a PPO or POS, should have out-of-network options. But if a health plan cannot provide the needed and medically necessary care in-network, you generally are entitled to go out of network. And often, especially with EPO or HMO plans, the plan must provide the care at the same member cost as in-network care. Remember that normally you would have a much higher copayment and deductible when using a provider that is not in-network.
In other words, if your deductible is $1,000 and you use an out-of-network medical provider. you will not only pay a higher copay, but your deductible could also be $3,000, $5,000, or even higher. When you request a network gap exception from your insurance company, you are asking your insurer to cover care provided by an out-of-network provider – at an in-network cost. Network gap exceptions are generally looked at individually. If your exception is granted, you will probably pay a lower copay and may be given the in-network deductible.
What if Your Health Insurer Does Not Have an In-Network Provider?
If you live rurally, it is more likely that your insurer will not have an in-network provider, particularly for a specialty doctor or procedure. If there is no in-network provider for the type of specialist, surgeon, or treatment you need in your area, it is not fair that you are required to bear the financial responsibility for the extra costs so the plans are often required to provide the care at the in-network cost. You are likely to have a more extensive medical network if you are on an employer-sponsored health plan, while a plan you purchased yourself is more likely to have a limited network.
Each state sets its own rules regarding the adequacy of each insurer’s network, which means there are likely to be wide variations from one state to another regarding what is considered “adequate.” As of 2025, there is a proposed change in rules that could require state-run insurers to follow the same standards regarding distance and time as HealthCare.gov (The Affordable Care Act) provides.
What is the Process for Obtaining a Network Gap Exception?
The most important thing to remember is that you should always ask for a network gap exception before getting the care or medical service. If you do not, your insurer will process your claim as out-of-network, and you may be responsible for the entire amount.
Once you locate an out-of-network provider that meets your needs, you can submit a request to your insurer for a network gap exception. Sometimes, the out-of-network provider may submit such a request on your behalf, but generally speaking, you will be responsible for submitting the exception request. You will often need the following information for a network gap exception request:
- The healthcare service or procedure will have a CPT or HCPCS code, which you can get from the out-of-network provider.
- Your diagnosis also has a code, known as an ICD-10 or ICD-11 code, which you will need for your exception request. (If you are unable to get these codes from your out-of-network provider because you have not yet seen them, your referring physician may be able to help you get them).
- You must provide the name, address, and phone number of your chosen out-of-network provider.
- You must provide a date range of when you expect to receive the requested service from an out-of-network provider in your request (i.e., between March 1, 2025, and May 30, 2025).
- If there are any in-network providers in your area that provide the service or treatment you need, include these in your exemption request, along with the reasons why each provider is incapable of providing the specific services you need.
What if Your Health Insurer Approves a Network Gap Exception?
Network gap exceptions are not common, and you are unlikely to be granted an exception unless:
- The medical care the exception concerns is considered medically necessary and would be a covered benefit under your plan if there was a provider in your area.
- There must be no provider within a “reasonable” distance from where you live who could see you within a “reasonable” wait time who is in-network.
If you are insured through the Affordable Care Act, a “reasonable” wait time is considered 10 business days for mental healthcare, 15 business days for primary care, and 30 days for specialty care that is non-urgent. Ask your insurer what it considers a reasonable wait time and distance.
As you attempt to set up a network gap exception for a specific medical provider and a specific service, ask about the financial details. If the network gap exception is granted, there is a chance they will accept the rates set by your healthcare plan as payment in full. If not, ask about what you will personally be responsible for paying.
Remember the Following Facts About Network Gap Exceptions
If you do all the work and your network gap exception is approved, remember that the approval is only for one specific service during a very limited time frame. You cannot return to this out-of-network provider time and time again without a network gap exception approval for each visit. If your network gap exception is denied, call your health insurer to determine the reason. There could be a very simple reason that can easily be fixed, and then your network gap exception could be approved.
How the Law Offices of Scott Glovsky Can Help with Your Network Gap Exception
If you need assistance with your request for a network gap exception, consider contacting attorney Scott Glovsky. Scott has spent the majority of his career fighting for those whose insurance companies have left them struggling on their own to get the medical treatments and services they need.
Scott Glovsky routinely takes on huge insurance companies who believe they are untouchable. When these big companies take advantage of people who have nowhere to turn, Scott steps in to make a positive difference. Attorney Scott Glovsky loves being a trial lawyer as he fights for justice for his clients. In many cases, Scott and his legal team could be your last chance to get the care you need and deserve. Contact the Law Offices of Scott Glovsky today.