​Did you know that if your health insurer or health maintenance organization (HMO) cannot provide reasonable access to an in-network specialist or non-physician specialist with the professional training and expertise to treat a condition or disease, you can ask the health insurer or HMO for approval to see a specialist that is not part of the health insurer’s or HMO’s provider panel? 

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. And when you make your request, they have to respond quickly. ​

You can contact your health plan using the number on the back of your card, or use the link: https://bit.ly/miaccp ​to find out the process to use for your insurance company. 

You must request approval from your health insurer or HMO before you receive services, and you must use the company process. If you do not and you choose to see an out-of-network specialist, and in-network specialists were available, the services will be covered only if you have out-of-network benefits and only for the amount allowed for out-of-network coverage.

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,  your  health  plan  must  pay  the costs  of the out-of-network  specialist’s  services  other  than  your  cost-sharing  amount  (deductible, copay,  coinsurance), which you must  pay. Your health plan must ensure that the approved out-of-network services cost you no more than you  would  have paid if you received the services from a provider on the plan’s provider panel. This means there will be no balance bill.

If your request is denied, you have the right to appeal the denial. Review your plan to make sure you  know the rules. Your health benefit plan may not pay for services from an out-of-network provider in certain situations where you did not follow the health plans process for approval to see the out of network specialist. If you have questions, feel free to contact us at 800-492-6116.