Network gap: when no in-network provider can do it
If the plan's network has no provider with the needed expertise within a reasonable distance or time, you can ask for a network-gap (single-case) exception so the out-of-network provider is paid at the in-network level; marketplace plans are also held to network adequacy standards. The request works best before the care, with the evidence that you looked.
When it applies
- Specialised surgery, rare-disease care, paediatric subspecialties, gender-affirming care, complex cancer surgery where the network is thin
- HMOs and EPOs with no out-of-network benefit, where the exception is the only path
Where it does not
- Preference for a particular out-of-network clinician when a qualified in-network one is available
- Plans with a robust out-of-network benefit already covering the care
The sentence to put in the appeal
“I request a network-gap exception to receive [service] from [provider] at in-network cost-sharing. The plan's network does not include a provider who [performs this procedure / treats this condition / can see me within a clinically appropriate time] within [distance], as documented below. Marketplace plans must maintain a network sufficient in number and type of providers under 45 CFR 156.230; where the network cannot provide the covered service, the plan must arrange it at in-network cost.”
Replace the bracketed parts with your facts. Cite the regulation exactly as written; quote the plan’s own wording next to it.
How to use it
- Step 1
Document the search
Names, dates and answers from in-network providers you contacted; wait times; distances.
- Step 2
Have the referring clinician write
Why the specific expertise is needed and why the in-network options are not equivalent.
- Step 3
Get the answer in writing before the care
A verbal 'we will cover it' is not an authorisation. Ask for the exception letter.
Worked example
A complex jaw surgery had no in-network oral surgeon within 150 miles. The family submitted the search log and the surgeon's letter; the plan approved the out-of-network surgeon at in-network rates before the procedure.
Illustrative composite; details vary by plan and record. Outcomes are not guaranteed.
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Sources
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