Choosing Your Providers: In-Network and Out-of-Network​

​Your Primary Care Provider is your first stop for health care. It’s where you call or visit each time you need care. They help you get services from any specialists or other health professionals that you need. 

Your insurer may assign you to a Primary Care Provider. Usually you can change providers if you don’t like the one the plan assigns you. Contact your insurer to find out how. 

For most people, it makes sense to pick a Primary Care Provider from your health plan’s network. You’ll pay the least money out-of-pocket if you use providers in your plan’s network. That’s because the plan has negotiated contracts with the providers.

To find the names of providers near you who are in your health plan’s network, first you need to know the name of the network. You’ll find the name in your insurance policy or certificate or on your insurance card. Then, go on your insurer’s website and look for the directory of network providers. Or, you can call your insurer. The phone number is on your insurance card. If your health plan is through work, your employer may have a provider directory.

After you find a provider you want to use, call their office and ask:​

1. Are you in my plan’s network?
2. Are you accepting new patients?​

If you need help, call your insurer. The number is on your insurance card. If you need specialized health care, check whether your local hospitals or specialists are part of your plan’s network.​

What if I need to see an out-of-network provider?

If you use a provider outside of your health plan’s network when it’s not an emergency, you may pay more. However, sometimes, you may not be able to get the health care that you need from a specialist who is in your insurance company’s network. The in-network specialist may be unreasonably far away, or might not have an appointment for an unreasonably long time, or may not be able to treat your condition. When that happens, and you have to go to a specialist that is out-of-network, your insurance company may have to cover the out-of-network specialist the same as they would an in-network specialist. Your health insurance company has to have a process that you can use to find out how to get in-network coverage for care by an out-of-network specialist.​

Under Maryland law, if your health insurance plan does not have an in-network specialist who can provide medically necessary services to treat your condition or disease without requiring you to travel an unreasonable distance or wait an unreasonable amount of time, you can ask for approval from the health plan to see an out-of-network specialist. If certain conditions are met, your health plan will be required to cover the services you receive from the out-of-network specialist and process your claims applying your in-network deductible, coinsurance, or copayment.

Unless it’s an emergency, you must seek approval before your visit to the out-of-network specialist. You must use the company process. You can call the number on the back of your insurance card, or find the process at here.

If you do not seek prior approval and choose to see an out-of-network specialist, and in-network specialists were available, the services will be covered only if you have out-ofnetwork benefits and only for the amount allowed for out-of-network coverage. If you are not getting the assistance you need fast enough, the Maryland Insurance Administration can help you.

Watch this video to learn more:​​

​​Avoid Balance Billing 

Balance bills happen when a provider who isn’t in your health plan’s network charges more than your plan pays, and the provider bills you for the difference for services covered by your health plan. In-network providers have agreed to accept the plan’s payment as full payment and will not send you a balance bill. So, you can avoid the extra cost of balance bills if you choose providers in your health plan’s network.​

Sometimes you may not be able to choose a provider who is in your plan’s network. You may need emergency treatment, or you may see an out-of-network provider at an in-network hospital. Under the federal No Surprises Act, health plans may not balance bill when:

1. You receive covered emergency services from an out-of-network provider or an out-of-network emergency facility.
   
2. You receive covered non-emergency services from an out-of-network provider while visiting an in-network health care facility, unless you willingly give written consent in advance to give up your protections. You can never be asked to waive your protections for emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, and intensivist services, and you will never be balanced billed for these services at an in-network facility.
3. You receive covered air ambulance services provided by an out-of-network provider of air ambulance services.​
   

Additionally, beginning on January 1, 2023, if you are approved to see an out-of-network specialist for mental health or substance use disorder services, Maryland law protects you from balance billing.​

Job-Based Health Plans 

Your health plan may be through your job or a family member’s job. If the employer pays the costs of the health care services these plans cover, the plan is called a self-funded health plan. Many large employers, unions, government agencies, and school districts have self-funded health plans.​

Self-funded health plans usually use a third-party administrator (TPA) to review and pay claims for the plan. Sometimes, that TPA shares a brand name with a health insurer. But the employer still is responsible to provide the money to pay claims – not the insurer. If a unit of government is the employer, then the government is responsible to provide the money to pay claims.

The U.S. Department of Labor’s Employee Benefits Security Administration (DOL-EBSA) regulates self-funded health plans. State insurance laws generally don’t apply to selffunded plans.

Some employer-based plans are fully insured. Unlike self-funded plans, in a fully-insured plan, an insurer is responsible for covered health care costs. The insurer charges your employer a premium to take on that financial responsibility.

The Maryland Insurance Administration regulates fully-insured health plans. These plans, if issued in Maryland, must follow Maryland’s insurance laws. The Maryland Insurance Administration can help consumers who have fully-insured plans. If you have coverage under a group plan issued in another jurisdiction, the other jurisdiction’s laws will apply.

​Get free help with your health coverage! ​

The Maryland Insurance Administration has a Health Coverage Assistance Team (H-CAT) to assist consumers. If you have questions or concerns about health coverage for you or your loved ones, the H-CAT staff is here for you.