Exemptions to the Individual Mandate
There are some cases where there is no penalty to not having coverage.
Services are “out-of-network” if they’re from a doctor, hospital, or other provider that doesn’t have a contractual relationship with a particular health plan.
Not all plans cover out-of-network services
When they do, your share of the cost is usually higher than an in-network service.
You want to find out whether a provider is in-network before you receive any services. You also want to find out if your regular health care providers are in-network before you buy a plan.
The Affordable Care Act (ACA) limits how much money a person is required to spend on his or her family’s health care. But, out-of-network services do not count toward these limits.
A plan’s Statement of Benefits and Coverage (SBC) will include information about coverage for out-of-network services.
The Health Insurance Marketplace and the SHOP Marketplace for Small Businesses include links to insurance company websites. These will let you look up if your doctor is in a plan’s network.
It’s always a good idea to also check with the doctor or dentist before you schedule an appointment. This will make sure the information on the website is correct.
The ACA requires any health plan that provides benefits for emergency services to cover you regardless of whether the provider is in- or out-of-network.
Under the ACA, health plans can’t charge a higher copayment or coinsurance for out-of-network services you get in an emergency.
Kansas also prohibits balance billing for emergency care you get out-of-network. This means only in-network rates will apply for all emergency care.
This article is published on KansasMoney.gov. Find more information by contacting these state agencies: