The insurance network is closed. Now what?

The short answer: ask which network is closed (product, provider type, level of care, county) and get it in writing; then send the plan's network management team a network need letter showing the gap its members face (distance, waits, a missing level of care, languages) and what you fill. For individual clients, use single case agreements and, for state-regulated Texas plans, the network gap exception rules. If it's still no, reapply on the date the plan gives you, with something new to show.

What "closed" usually means

A plan decides who it contracts with. When it says the network is closed, it usually means it believes it already has enough providers of your type, in your area, for its members. That answer is often narrower than it sounds:

• It may be about clinicians, not facilities. Plans close panels to new individual therapists in big cities far more often than to programs. A rep reading from the individual script may not know the facility answer.
• It may be one product. A plan can be closed for its commercial network and open for its Medicare Advantage, Medicaid or marketplace networks, or the other way around.
• It may be one level of care. Plenty of outpatient therapists doesn't mean enough PHP or evening IOP for substance use.
• It may be the wrong company. If a behavioral health company manages the benefit (Evernorth for Cigna, Optum for UnitedHealthcare, Carelon or Magellan for some plans), the medical plan's answer doesn't count. See behavioral health carve-outs.

Five questions to ask first

1. Which network is closed? Commercial, Medicare Advantage, Medicaid or marketplace, and for which provider type: individual clinicians, groups or facilities.
2. For which levels of care and which counties?
3. Can I have that in writing, with the reason?
4. Is there an exception process, and where do I send a request? Get the name of the network management or contracting team, not just provider services.
5. When can I reapply, and does the plan review its network on a set schedule?

Write down the rep's name, the date and the reference number for every call. That log is part of your evidence later.

The network need letter

An exception request works when it shows the plan a gap in its own network that you fill. Keep it to two pages, factual, and about the plan's members, never about your revenue. Never include client names or anything that identifies a client; use counts.

What to put in it

Section	What makes it persuasive
Who you are	Legal name, NPI, tax ID, address, the state license and levels of care, accreditation if you have it, and the counties you serve.
The access gap	The in-network programs at your level of care listed in the plan's own directory, with the distance and drive time from your area to each, and what each told you when you called about its soonest admission. Directory entries that don't run the program, aren't taking clients or don't answer count too.
What you offer that's missing	A level of care (PHP, or IOP for substance use), evening or weekend hours for people who work, adolescents, co-occurring mental health and substance use care, medication for addiction treatment, trauma-focused or gender-specific groups, and clinicians who speak the members' languages, such as Spanish.
Demand from the plan's own members	How many of the plan's members asked for your program in the last six months, how many single case agreements the plan already approved with you, and how many members you had to refer elsewhere. Counts only.
Quality	Accreditation, time from referral to admission, completion rates and results on a standard measure repeated over time. Only numbers you can back up.
The ask	A facility agreement for named levels of care, and a request for a written decision with the reason. If you'll want better than the standard fee schedule, see negotiating insurance rates for the data to gather now.

Send it to the network management or contracting contact the plan named, keep proof of when it went, and follow up every two weeks. If you already have single case agreements with the plan, mention them: each one is the plan agreeing in writing that its network couldn't serve that member. Our single case agreement guide covers how to win them.

Texas network adequacy rules

Texas sets network adequacy standards for the health plans it regulates. They're written to protect members' access, not to make a plan contract with any provider who asks. Use them as evidence and as leverage for individual clients, not as a right to a contract.

PPO and EPO plans (state-regulated)

• The plan must keep its network adequate. Texas Insurance Code §1301.0055, rewritten by House Bill 3359 in 2023, has the commissioner set network adequacy standards, including time and distance and appointment wait-time standards, and TDI adopted updated rules in 2024.
• Gaps must be disclosed and waived. When a network doesn't meet the standards for a provider type in a county, the insurer has to apply for a waiver. TDI decides after a public hearing, and (per TDI's network adequacy waiver FAQ) anyone, including a provider, can submit information before or during the hearing or testify. TDI publishes the waiver requests insurers file, so you can see whether a plan has already admitted a behavioral health gap in your county.
• Members can get a network gap exception. TDI's rules (28 TAC §3.3707) require insurers to have a documented procedure for members when no preferred provider is reasonably available, decided within five business days. When covered services aren't available from a preferred provider in the service area, Texas Insurance Code §1301.005(b) requires the plan to pay at the in-network level.

HMOs (state-regulated)

• When medically necessary covered services aren't available from network providers, Texas Insurance Code §1271.055 requires the HMO, at a network provider's request, to allow a referral to a non-network provider and pay it in full at the usual and customary rate or an agreed rate. Before denying the request, the HMO must have it reviewed by a specialist of the same or similar type.
• The request has to come from a network provider, such as the member's primary care physician or psychiatrist, so ask that office to send it.

These rules change, and parts of TDI's out-of-network rules have been challenged in court. Read the current rule text, or ask TDI, before you quote it in a letter.

Who regulates the plan, and where to complain

Before you lean on any rule, find out who regulates the client's plan. TDI says a card without "TDI" or "DOI" on it is from a self-funded plan, which TDI doesn't regulate.

Plan type	Who regulates it	Where to go
Fully insured PPO, EPO or HMO (card says TDI or DOI)	Texas Department of Insurance	The member can file a complaint with TDI online or through its Help Line (800-252-3439). Providers with claim-payment problems use TDI's prompt pay and provider complaint process.
Self-funded employer plan (no TDI or DOI mark, or "administered by")	U.S. Department of Labor (ERISA), for private employers	The plan's own appeal process, then the Department of Labor's Employee Benefits Security Administration. The employer's HR or benefits team can also press the administrator.
Government, school, church or union plan	Varies	The complaint process in the plan's benefits booklet.
Texas Medicaid or CHIP managed care	HHSC sets the plans' contract terms	The plan's provider relations first, then HHSC's managed care complaint process. Check HHSC's current route.

A complaint won't force a contract, but a member's complaint about access to care gets a plan's attention, and it creates a record if the plan's network really is short.

Reapplying

• Get the denial in writing, with the reason and the earliest date you can reapply, and put that date on the calendar.
• Change something before you reapply: accreditation (our Program Launch + Accreditation carries a program through the survey), a new level of care, an evening track, a bilingual clinician, a second location in an underserved county, or a stack of single case agreements with that plan.
• Try the plan's other networks. A plan closed for commercial may be recruiting for its Medicaid managed care or marketplace network.
• Ask your referral sources to tell the plan when they can't find an in-network program for its members. Hospitals and case managers carry weight. No client details, and nothing of value in return for referrals.

The alternatives

• Single case agreements, one client at a time, at a rate agreed in writing before admission. See the single case agreement guide.
• Out-of-network benefits. Many PPO members have them. Verify the benefit and the authorization, and give the client their cost in writing. Quick VOB's VOB checklist lists what to ask.
• Other plans. Put your effort where the network is open (our credentialing team checks each plan's status before filing): Texas Medicaid managed care plans in your service area, marketplace plans, TRICARE once you're accredited, and the VA Community Care Network.
• Self-pay, with a good faith estimate before services.
• Buying or merging with a contracted program doesn't hand you its contracts automatically. Contracts usually limit assignment and a change of ownership; read them with your attorney first.
• Never bill under another provider's contract, license or NPI.

Start with the full picture in how to get insurance contracts for an IOP or PHP, or book a free 30-minute call.

Questions

Can an insurance company refuse to contract with my treatment program?

Yes. Plans choose their networks, and Texas network adequacy rules protect members' access rather than giving any provider a right to a contract. What changes a plan's mind is evidence of a gap its members feel: distance, waits, a missing level of care, languages, and single case agreements it has already had to grant.

What is a network need letter?

A short, factual letter asking a plan for a contract as an exception to a closed network. It names the gap in the plan's own network (the in-network options, their distance and their wait times), what you offer that's missing, demand from the plan's members in counts only, and your quality record.

Does Texas law make a plan pay in-network rates when it has no in-network provider?

For state-regulated PPO plans, Texas Insurance Code §1301.005(b) requires payment at the in-network level when covered services aren't available from a preferred provider in the service area, and TDI's rules require a network gap exception procedure. State-regulated HMOs must allow a referral out of network in that situation. Self-funded employer plans aren't covered by these Texas rules.

Should I file a complaint with TDI if a plan won't contract with us?

A refusal to contract alone usually isn't a violation. A complaint fits better when a member can't get care in the plan's network, when a plan won't follow its own gap exception process, or when it doesn't pay claims on time. If the plan is self-funded, TDI can't help; go to the plan's appeal process and the Department of Labor.

How soon can I reapply after a denial?

Each plan sets its own wait. Ask for the date in writing with the denial, put it on the calendar, and change something meaningful before you reapply.

Sources

• Texas Department of Insurance, EPO and PPO network adequacy and network adequacy waiver FAQ; network adequacy waiver requests (open data)
• Texas Legislature, House Bill 3359 (2023), enrolled text amending Insurance Code §1301.0055
• Texas Insurance Code §1271.055 (HMO out-of-network services); 28 TAC §11.1611; 28 TAC §3.3704 (availability of preferred providers); 28 TAC §3.3707
• Texas Department of Insurance, File a health insurance complaint, Self-funded plans and Prompt pay