How to know when your insurance network is inadequate.
Are you having trouble finding a mental health or substance use disorder provider who takes your insurance?
By law, health insurance companies are supposed to have enough providers in their plan to meet the needs of the people who use it. When they do not it is called an inadequate provider network. Below are some examples of things that might happen with a health insurance company has an inadequate provider network.
- Long wait times to see providers in your network.
- All the providers in your network are not taking new patients.
- Few or none of the providers in your network can treat your condition.
- The provider directory is wrong or not up to date.
- The directory lists providers as in-network when they’re not.
- It has the wrong contact information for the provider.
- The only option for treatment is telehealth and there are no in-person services.
- All available providers are far away, and you would have to travel a long distance to see them.
What can you do?
Does your insurance plan sound like the examples above? If it does, then the insurance network may be inadequate.
To try and get the insurance company to make their network better you can file a complaint with the government. However, where you file the complaint will depend on the type of insurance plan you have.
If you have a Medicare or Medicare Advantage plan you can file a complaint with Centers for Medicare and Medicaid Services.
If you have a Medicaid Managed Care plan you can file a complaint with the Department of Health.
If you have a commercial plan you can file a complaint with the New York State Department of Financial Services.
What is the difference between a complaint and an appeal?
A complaint is about the quality of care you got or are getting. For example, you can file a complaint if you have a problem calling the plan, or you’re unhappy with how a staff person at the plan treated you.
You file an appeal if you have an issue with a plan’s refusal to cover a service, supply, or prescription.
