Out-of-Network (OON)

Services received from a provider who does not have a contract with the member's health plan. OON benefits are often reduced or excluded. When a plan's in-network behavioral health network is inadequate, some members can ask the plan to cover an OON provider at in-network cost-sharing — usually through a 'single case agreement' or a 'network gap exception.' This is not a universal right. For state-regulated (fully-insured) plans, a gap exception may be required by state insurance law, and those laws vary by state. For self-funded ERISA plans it is generally discretionary and granted under the plan's own terms rather than mandated by federal law. Traditional Medicare, Medicaid, and Tricare follow their own separate rules. Whether a gap exception is available to you depends on your plan type, your state, and your plan document — check your Summary of Benefits and Coverage or ask the plan in writing. Where a network adequacy failure exists, it may also be worth raising as a possible MHPAEA non-quantitative treatment limitation (NQTL) issue on plans that MHPAEA covers.