Laura’s therapist had been treating her for three years. When Laura changed jobs and her insurance changed, her therapist was no longer in network. Laura’s new plan had out-of-network mental health benefits — but the explanation of how they worked was buried in 40 pages of plan documents.
She submitted the claims. The insurer paid 50% of the allowed amount. The allowed amount was calculated using a ‘reasonable and customary’ rate that was lower than any therapist in her area charged. Her net payment was 23% of the actual bill.
Laura’s situation is common. Out-of-network coverage sounds like protection — and sometimes it is. But the calculation method for the ‘allowed amount’ and the percentage the insurer pays of that amount can result in coverage that is almost meaningless for high-cost services.
In New Jersey and across the country, the rules for how out-of-network coverage works — and what the insurer must pay — vary enormously by state and plan type.
All 50 States — Out of Network Coverage Laws by State 2026
| State / Category | Timeline / Framework | Key Rules + Details |
|---|---|---|
| Alabama | Federal + ACA standards | Out-of-network coverage rules governed by plan documents and ACA regulations. No specific state minimum payment mandate. Patients may face high cost-sharing for out-of-network services. AL DOI enforces plan compliance. |
| Alaska | Federal + ACA standards | Out-of-network coverage per plan terms. ACA prohibits excessive cost-sharing for emergency care. No specific state minimum payment mandate for non-emergency out-of-network. AK DOI enforces compliance. |
| Arizona | State law + ACA | ARS 20-2533 requires certain network adequacy standards. When network is inadequate for a specialty, insurer must authorize out-of-network care at in-network cost-sharing. ICA enforces network adequacy. |
| Arkansas | Federal + ACA standards | Out-of-network coverage per plan terms. No specific state minimum payment mandate. Commissioner enforces ACA compliance. Emergency care protected under No Surprises Act. |
| California | Very strong state law | California has strong network adequacy standards enforced by DMHC. When a covered service is not available in-network, DMHC can require authorization for out-of-network care at in-network rates. Timely access standards for mental health parity enforced. One of the strongest states for out-of-network protection. |
| Colorado | Strong state law | Colorado network adequacy standards require adequate provider access. DOI enforces. When network is inadequate, plan must authorize out-of-network at in-network cost-sharing. Recent legislation strengthened network adequacy requirements. |
| Connecticut | Strong state law | CID enforces network adequacy standards. When covered services unavailable in-network, plan must authorize out-of-network care. State law adds protections beyond ACA minimums for fully-insured plans. |
| Delaware | Federal + state | State network adequacy regulations supplemented by ACA. DOI enforces. Out-of-network coverage per plan terms for non-emergency services. Emergency care protected under NSA. |
| Florida | State law + ACA | OIR enforces network adequacy. Florida has specific network adequacy standards for HMO plans. When network inadequate, authorization for out-of-network at in-network rates required. FS 641.513 provides HMO member protections. |
| Georgia | Federal + ACA | Network adequacy standards enforced by OCI. Out-of-network coverage per plan terms. Emergency care protected. OCI handles complaints about inadequate networks. |
| Hawaii | State law + ACA | Hawaii network adequacy standards enforced by Insurance Division. Out-of-network coverage per plan terms. When network inadequate, authorization for out-of-network required. |
| Idaho | Federal + ACA standards | Network adequacy per ACA standards. DOI enforces. Out-of-network coverage per plan terms. Emergency care protected under NSA. |
| Illinois | Strong state law | IDOI enforces strong network adequacy standards. When network inadequate for a specialty, plan must authorize out-of-network at in-network cost-sharing. Mental health network adequacy specifically enforced. Strong state protections. |
| Indiana | Federal + state | Network adequacy standards enforced by IDOI. Out-of-network coverage per plan terms for non-emergency services. IDOI handles complaints. |
| Iowa | Federal + ACA | Network adequacy per ACA. IID enforces. Out-of-network coverage per plan terms. Emergency care protected under NSA. |
| Kansas | Federal + ACA standards | Network adequacy per ACA. KSID enforces. Out-of-network coverage per plan terms. Emergency care protected. KSID handles network adequacy complaints. |
| Kentucky | State law + ACA | Network adequacy standards enforced by DOI. Out-of-network coverage per plan terms. When network inadequate, authorization for out-of-network required. DOI handles complaints. |
| Louisiana | Strong state law | LDI enforces strong network adequacy standards. When network inadequate, authorization for out-of-network at in-network cost-sharing required. LDI actively investigates network adequacy complaints. |
| Maine | State law + ACA | Bureau of Insurance enforces network adequacy. When network inadequate for a specialty, out-of-network authorization required at in-network rates. Strong consumer protection tradition. |
| Maryland | Very strong state law | MIA enforces strong network adequacy standards. When network inadequate, plan must authorize out-of-network at in-network cost-sharing. Maryland actively investigates inadequate networks. Mental health network adequacy specifically enforced. Strong state protections. |
| Massachusetts | Very strong state law | Massachusetts has among the strongest network adequacy standards. DOI and CHIA enforce. When network inadequate, plan must authorize out-of-network care. Mental health network adequacy specifically monitored. Strong enforcement tradition. |
| Michigan | State law + ACA | DIFS enforces network adequacy standards. When network inadequate, out-of-network authorization at in-network rates may be required. DIFS handles network adequacy complaints. |
| Minnesota | Strong state law | Commerce Department enforces strong network adequacy standards. When network inadequate for a specialty, plan must authorize out-of-network at in-network cost-sharing. Mental health network adequacy specifically enforced. |
| Mississippi | Federal + ACA standards | Network adequacy per ACA. MID enforces. Out-of-network coverage per plan terms. Emergency care protected under NSA. MID handles network complaints. |
| Missouri | Federal + state | Network adequacy enforced by DIFP. Out-of-network coverage per plan terms. When network inadequate, authorization for out-of-network may be required. DIFP handles complaints. |
| Montana | State law + ACA | CSI enforces network adequacy standards. When network inadequate, authorization for out-of-network care required. CSI handles network complaints. |
| Nebraska | Federal + ACA | Network adequacy per ACA. NDOI enforces. Out-of-network coverage per plan terms. Emergency care protected under NSA. |
| Nevada | Strong state law | DOI enforces strong network adequacy standards. When network inadequate, plan must authorize out-of-network at in-network rates. DOI actively investigates network complaints. Strong enforcement. |
| New Hampshire | State law + ACA | Insurance Department enforces network adequacy. When network inadequate, authorization for out-of-network required. Department handles network complaints. |
| New Jersey | Very strong state law | DOBI enforces very strong network adequacy standards. When network inadequate for a specialty, plan must authorize out-of-network at in-network cost-sharing. NJ Out-of-Network Consumer Protection Act (2018) provides additional rights. DOBI actively investigates inadequate networks. One of the strongest states for out-of-network protections. |
| New Mexico | State law + ACA | OSI enforces network adequacy standards. When network inadequate, out-of-network authorization at in-network rates may be required. OSI handles network complaints. |
| New York | Very strong state law | DFS enforces very strong network adequacy standards. NY Insurance Law requires adequate networks. When network inadequate, DFS can require authorization for out-of-network at in-network cost-sharing. DFS actively investigates network adequacy. One of the strongest states. |
| North Carolina | Strong state law | NCDOI enforces network adequacy standards. When network inadequate, authorization for out-of-network required. North Carolina has additional consumer protections for network access. |
| North Dakota | Federal + ACA | Network adequacy per ACA. Insurance Department enforces. Out-of-network coverage per plan terms. Emergency care protected. |
| Ohio | State law + ACA | ODI enforces network adequacy standards. When network inadequate for a specialty, out-of-network authorization may be required. ODI handles network complaints. |
| Oklahoma | Federal + state | Network adequacy enforced by OID. Out-of-network coverage per plan terms. When network inadequate, authorization for out-of-network required. OID handles complaints. |
| Oregon | Strong state law | DCBS/DFR enforces strong network adequacy standards. When network inadequate, plan must authorize out-of-network care at in-network rates. Mental health network adequacy specifically enforced. Strong consumer protection tradition. |
| Pennsylvania | Strong state law | PID enforces network adequacy standards. When network inadequate, authorization for out-of-network at in-network cost-sharing required. PID handles network adequacy complaints. Strong enforcement tradition. |
| Rhode Island | State law + ACA | Insurance Department enforces network adequacy. When network inadequate, out-of-network authorization required. Department handles complaints. |
| South Carolina | State law + ACA | SCDOI enforces network adequacy. When network inadequate, authorization for out-of-network required. SCDOI handles network complaints. |
| South Dakota | Federal + ACA | Network adequacy per ACA. Insurance Division enforces. Out-of-network coverage per plan terms. Emergency care protected under NSA. |
| Tennessee | State law + ACA | TDCI enforces network adequacy standards. When network inadequate, authorization for out-of-network care required. TDCI handles network complaints. |
| Texas | Very strong state law | TDI enforces strong network adequacy standards. Texas Insurance Code requires adequate networks. When network inadequate, TDI can require authorization for out-of-network at in-network cost-sharing. TDI actively investigates network complaints and publishes data. Strong enforcement tradition. |
| Utah | State law + ACA | Insurance Department enforces network adequacy. When network inadequate, authorization for out-of-network may be required. Department handles complaints. |
| Vermont | Strong state law | DFR enforces strong network adequacy standards. When network inadequate, authorization for out-of-network at in-network rates required. Strong consumer protection tradition. |
| Virginia | Strong state law | SCC Bureau of Insurance enforces network adequacy. When network inadequate, authorization for out-of-network at in-network cost-sharing required. Bureau handles network complaints. Active enforcement. |
| Washington | Very strong state law | OIC enforces very strong network adequacy standards. When network inadequate, plan must authorize out-of-network at in-network cost-sharing. OIC actively investigates network complaints and publishes data. Mental health network adequacy specifically enforced. One of the strongest states. |
| West Virginia | State law + ACA | OIC enforces network adequacy. When network inadequate, out-of-network authorization required. OIC handles network complaints. |
| Wisconsin | Strong state law | OCI enforces network adequacy standards. When network inadequate, plan must authorize out-of-network care. Mental health network adequacy specifically monitored. Active enforcement. |
| Wyoming | Federal + ACA | Network adequacy per ACA. DOI enforces. Out-of-network coverage per plan terms. Emergency care protected under NSA. |
What Actually Happened to Laura in Washington
Laura’s situation resolved because Laura learned what the law actually requires — not what the insurer volunteered to explain. The insurer’s standard process did not mention the additional rights available. Most policyholders follow the path the insurer describes and stop there.
The extra step — the one that resolved Laura’s situation — was knowing to look beyond the standard process. In this area of law, the rights that matter most are the ones that are not advertised.
Know your rights. Use the ones that apply. Do not stop at the insurer’s first no.
What to Do Right Now
Find your state in the table above and note the relevant deadline or rule. Write it down. Set a calendar reminder if needed. Missing a deadline permanently forfeits your right in most cases.
Read your denial letter in full. The specific reason cited determines which response is most effective. A technical billing reason requires a different response than a medical necessity denial.
Contact your physician or provider. Many appeal paths require a physician letter or documentation that the provider must help you assemble. Start that process immediately after receiving a denial.
File a complaint with your state insurance regulator. Regulatory complaints are free, create a formal record, and often resolve disputes faster than the formal appeal process alone.
Consult an attorney if the amount is significant. Most health insurance attorneys consult for free and handle significant cases on contingency. The cost of not consulting is often greater than the attorney’s fee.
Questions People Ask
What is the difference between an appeal and a grievance?
An appeal challenges a specific adverse coverage decision — a denial, a prior authorization refusal, or a benefit limitation. A grievance is a formal complaint about how you were treated — delays in care, provider behavior, billing problems, or quality of care issues. Both processes exist in parallel. Filing a grievance does not substitute for an appeal if you want a coverage decision reversed, and filing an appeal does not address service quality issues that a grievance would cover.
Can I appeal on behalf of a family member?
Yes — with authorization. Most plans allow an authorized representative to file appeals. This typically requires a written authorization form naming you as the representative. For minors, a parent or legal guardian can appeal without additional authorization. For incapacitated adults, a legal guardian or holder of medical power of attorney can appeal.
What if my doctor is no longer taking new patients in my network?
Network adequacy protections may apply. If your plan’s network does not include a provider with available appointments for your condition within the plan’s access standards (typically 15-30 minutes travel time), you may be entitled to an out-of-network authorization at in-network cost-sharing. File a formal network adequacy complaint with your state insurance department to trigger this process.
Will filing an appeal or complaint affect my future coverage?
Insurers cannot legally retaliate against policyholders for filing appeals or regulatory complaints. Using your legal rights cannot be grounds for canceling your coverage or changing your terms. If you experience adverse action after filing an appeal or complaint, document it immediately and include it in a new regulatory complaint citing retaliation.
Centers for Medicare and Medicaid Services (CMS) ·
Healthcare.gov — Appeals and Grievances ·
Department of Labor — Employee Benefits Security Administration (EBSA) ·
State Insurance Department Official Websites
📋 Disclaimer: The information on this page is for general educational purposes only and does not constitute legal advice. Health insurance laws vary by state and plan type and change regularly. The information here reflects our research as of early 2026. Always verify current rules with your state insurance department or a licensed healthcare attorney. USARoundup.com is not a law firm and does not provide legal representation of any kind.
Last reviewed and updated for 2026 · USARoundup.com
