What is a network gap exception?
A network gap can arise when a plan has no available in-network provider for a covered service you need. A network gap exception is a request for the insurer to cover care from an out-of-network provider under specified terms. Ask whether the plan would cover the care at in-network cost sharing and what the provider can bill you.
CMS says Marketplace members can ask their plan for an exception (opens in a new tab). A request is not an approval. There is no automatic guarantee that a particular out-of-network doctor will be covered at in-network rates. The name and process vary by plan, and your state rules, the service and the provider's agreement all matter.
This guide is about nonemergency care under an individual or family Marketplace plan. Employer plans, Medicare and Medicaid can have different rules. If you have an emergency, seek care immediately: Marketplace plans cannot require prior approval for emergency care from an out-of-network provider. Federal protections generally limit surprise bills, but you may still owe in-network deductibles, copays or coinsurance.
How do I start the request?
As you arrange nonemergency care, use the full plan name and network on your card. A clinic that accepts one plan from an insurer may not accept another.
- Search the exact plan's provider directory for the specialty, location and service you need. Call the offices to check whether they accept your specific plan and are taking patients.
- Call the member services number on your card. Ask the insurer for an available in-network specialist who can provide the covered service, how it assesses wait times, and note the names, dates, wait times and call reference numbers.
- If there is no appropriate in-network option, ask how to request a network gap or network adequacy exception. Ask whether you, your primary care clinician or the specialist must submit it.
- Ask whether a referral, medical records or separate prior authorization is required. Your treating clinician can explain the medical need to the plan.
- Before nonemergency care, ask for the decision and financial terms in writing. Confirm the named provider, facility, services, dates, your share of the cost and whether the provider accepts the arrangement.
You can say: "I need a covered specialist and have not found an available in-network provider. Can you find one or explain how to request a network gap exception? Who submits it, and what will I owe if it is approved?"
If your clinician says care is time-sensitive, do not put it off while waiting for paperwork. Ask your clinician about safe alternatives and tell the insurer that the request may be urgent.
What should I ask about the bill?
| Question | Why it matters |
|---|---|
| Is the exception approved for this provider and service? | A general conversation or reference number is not the same as a written approval. |
| Is prior authorization or a referral also required? | The plan may require a separate approval or a request from your treating clinician. |
| What will I pay, and can the provider bill me more? | Ask about deductibles, copays, coinsurance and any possible balance bill. Confirm that the provider accepts the arrangement. |
| Which facility, dates and services are included? | An approval may be limited. Ask what happens if the appointment or treatment changes. |
Do not assume that an out-of-network specialist must accept your plan's payment or that an approval covers every related facility, test or follow-up visit. Keep the insurer's decision and the provider's billing answer.
What does one Marketplace insurer say?
As a specific example, UnitedHealthcare's Individual Exchange guide for out-of-network providers (opens in a new tab), dated 2024, says a primary care provider may request a benefit exception when a nonemergency service is not offered by a participating provider. It says a member can call the number on their card; the insurer first attempts to find in-network care and describes a gap exception process if no in-network provider is available.
That guide is for UnitedHealthcare Individual Exchange plans, not every UnitedHealthcare product or every insurer. It is older than the 2027 plan year and is only an example. Ask for your current Evidence of Coverage and call the insurer to confirm your plan's present process and terms. Approval is not automatic.
If you have a Florida UnitedHealthcare Marketplace plan, our Florida insurer reference links to its 2027 provider lookup. Search the exact plan and confirm results with the insurer and provider. Our public-file reference does not establish specialist availability or approve an exception.
For another insurer or state, start with our Insurers & Hospitals directory and then use the directory for your own plan. A hospital listing alone does not establish that an individual specialist is in network.
What if the insurer says no?
Ask for the reason and the written decision, including any appeal instructions and deadline. Depending on the decision, you may be able to request an internal appeal and an independent external review. HealthCare.gov explains insurance appeals (opens in a new tab) and where to begin.
If you are already receiving treatment and your provider leaves the network, ask about continuity of care as well. That is a different question from whether a new network gap exception is available.
Not finding a specialist does not automatically give you a Special Enrollment Period to switch plans. You can compare other plans during the applicable open enrollment period, or ask the Marketplace whether another qualifying event applies. Our plan network comparison explains the basic differences between HMOs and PPOs.
If your Marketplace plan is regulated in Florida, the Florida Department of Financial Services (opens in a new tab) can explain consumer assistance and complaint options. For another state, use the state insurance department directory (opens in a new tab). If you are unsure who regulates your plan, ask the insurer or a consumer assistance program (opens in a new tab).
Insurers and hospitals mentioned
Explore the organizations or brands discussed in this article. A mention does not mean every plan or location is covered.
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We can help you compare the Marketplace plans we offer where we are licensed and show you where to check their provider networks. Your insurer and treating clinicians handle exception requests; approval is not guaranteed, and we do not offer every plan.