Providence is very thorough and thoughtful about contracting with providers to bring you quality, evidence-based and comprehensive care. Effective Jan. 1, 2014, The Affordable Care Act includes non-discrimination language that restricts health plans, such as Providence, from discriminating against health care providers when the provider practices within the scope of his or her license and participates according to the plan's terms and conditions. Providence, however, may not contract with every type of provider or provider category. Similarly, insurance carriers are not required to cover every health service that a provider may be licensed to provide. If a service is excluded from your plan, that service is excluded for every provider type.
What does this mean for you?
- If you access care from an in-plan provider who practices within the scope of his or her license, and according to the plan's terms and conditions, your health plan pays for services according to your plan's benefit.
- If your plan does not have out-of-plan benefits and you access care from an out-of-plan, non-participating provider, then the services will not be covered by insurance. In other words, services are not covered by your health plan if they are received from an out-of-plan provider when the plan does not have out-of-plan benefits.
- If your plan has out-of-plan benefits and you access covered services from an out-of-plan provider who practices within the scope of his or her license, your care may be covered at the out-of-plan benefit level. For instance, if your plan has out-of-plan benefits and you access maternity services from an out-of-plan, non-participating birth center, this may be a covered at your plan's out-of-plan benefit level.