What do I do if all the in-network providers covered by insurance have long wait lists?

Your health plan contracts with in-network providers they will cover to reduce your out-of-pocket costs for your child's care, but what if all those in-network providers have lengthy wait lists?

Undivided's Director of Health Plan Advocacy, Leslie Lobel, says that you can reach out independently to providers in your area who have availability and ask if they are willing to negotiate a single-case agreement with your health plan at an acceptable rate. Then, go to your child's doctor and ask to be referred to that provider. If you present someone who is willing to negotiate and work with the health plan, insurance may approve coverage. You can also find out if there is an overflow provider that the insurance is already contracted with.

Every insurance is legally obligated to provide reasonable access to covered benefits, absent medical benefits that are available on the plan.

It may also be possible to advocate for your health plan to cover an out-of-network provider at the in-network rate. You should start by obtaining the health plan’s network contracted provider list, and make calls to confirm that none of these contracted providers are able to deliver the care your child requires. A general rule of thumb is that if a provider's wait list is longer than six months, they are not a suitable provider for your child, and you can appeal to your health plan based on lack of access to care.

See our step-by-step guidance to help you advocate for network-level reimbursement from your health plan.