When you have a good relationship with your doctor, it’s almost like magic — especially if you’ve ever had a doctor you’ve disliked. After all, a good doctor-patient relationship can do wonders for the quality of your health care. You’re more likely to be open and candid, and the doctor is more likely to listen closely and provide better care.
That’s why it can be so disappointing to find that your doctor is no longer in your network, meaning your health insurance company no longer covers your visits, or covers them at a lower level. Although most people would love to stick with a trusted provider, out-of-network doctors’ fees are often too steep to pay out of pocket.
But for many who are insured through an employer or spouse’s employer, you can’t switch to an insurance policy that does cover your doctor until open enrollment later in the year. That is, unless your employer plan offers mid-year changes (very rare) or you experience certain life events such as marriage, divorce or a new job.
Still, as Trisha Torrey, founder of the Alliance of Professional Health Advocates, sees it, patients essentially have three main options when a doctor leaves their health plan: You could change health plans, when you’re able to do so to one that your doctor participates in if such coverage is available (it may not be among plans you have to pick from, like those offered by an employer); negotiate a cash price to continue seeing your doctor (the willingness of a doctor’s office to do this, the cost and what’s affordable for each individual will certainly vary considerably); or, of course, set about finding a new doctor.
[See: How to Pick a Health Insurance Plan.]
Why Do Doctors Leave Health Insurance Networks?
It’s not uncommon for doctors to enter and leave health insurance networks. “Doctors are professionals just like the rest of us. They move, they retire and sometimes they just can’t work with an insurer anymore for various reasons,” says Sally Poblete, a health insurance expert and CEO of Wellthie, a technology company that helps consumers make health insurance decisions.
When your doctor does drop out of your network, you’ll probably be warned. “Most doctors inform their patients ahead of such a change so they have time to plan,” says Poblete, but neither doctors nor insurers are mandated to do so.
That means you might get a nice letter in the mail informing you of an upcoming change — or a bill after services are rendered for an amount way higher than your normal copay or coinsurance. Either way, here’s what to do.
Find Out if You’re Protected
Depending upon where you live, you may be able to retain in-network-level of coverage for your doctor — at least temporarily — even if he or she leaves your network. Check to see what continuity of care protections your state has in place. “If you have something like a pregnancy or an acute condition, continuity of care allows you to see your doctor until it’s over,” Poblete says. While protections vary, under these clauses, you may be able to continue paying the same copays and fees for your care until the baby is born or the condition resolves, for example, before you need to find a new provider.
Continuity of care is also available in some insurance plans without being required by law, Poblete says. In these cases, patients with serious chronic conditions or terminal illnesses may also keep their providers for up to 12 months in order to make a safe switch.
And there’s good news for the roughly 19 million seniors who have Medicare Advantage plans, private alternatives to government-run Medicare: Those with these insurance policies can leave their plans if their doctors do.
According to the updated Centers for Medicare and Medicaid Services guidebook, patients qualify to switch plans midyear if a network change is “considered significant based on the [effect] or potential to affect current plan enrollees.”
Medicare Advantage patients whose doctors leave their plans have three months to switch to another Medicare Advantage plan or traditional, government-run Medicare. In this case, your insurance provider, not your doctor, is responsible for informing you of the change.
[See: Which Practitioner Do I See, and When?]
For others covered by private health insurance who are considering switching plans, check with both the plan and the doctor’s office to learn if your physician is in a new plan you’re considering. Of course, what health providers are covered by a particular plan and which aren’t is always subject to change. “But if you confirm from both directions, the chances are pretty good that you’re going to be OK and your doctor’s going to be covered,” Torrey says.
If it’s not possible to switch plans, you can check to see if it would be affordable in the short or long term to pay cash to continue seeing your doctor. Though typically doctors bill insurance, and that’s what patients generally expect, Torrey says it may be worth checking if you can negotiate a lower cash price with the doctor’s office to maintain continuity of care. “Oftentimes they’ll give you a really good deal to pay cash because they don’t have to bill your insurance,” she says, which may reduce a provider’s administrative costs, not to mention the added hassle of processing claims.
However, for the patient paying out–of–pocket costs can add up, particularly if you see the doctor often, and a cash arrangement may just not fit within the budget. “You have to decide whether that doctor is worth the cash outlay based on the numbers they give you,” and whether you can afford the negotiated rate, Torrey says.
Ask for a Referral
If switching plans or paying cash aren’t viable options, but you really value your doctor’s opinion, it may still be worth getting the physician’s take — on a new doctor you can see.
“If you like your doctor, call and ask for a referral to another physician,” Poblete says. Or, Torrey suggests, ask that doctor or a nurse at the practice to weigh in on your whittled down list of possible candidates covered under your plan who you’re considering.
Doctors have different methods and philosophies of care, and are likely to refer you to someone with similar values — such as preferring lifestyle changes to medication increases or frequent phone follow-ups. If you like something specific about your doctor, say so when asking for the referral.
Just be sure to retain copies of your medical records from at least the past couple years, and further back if you have had ongoing health issues, including test results, before you leave the practice for good. “We have mostly electronic records now,” Torrey says. “But just because you have access to an electronic record with the doctor you’ve got now, doesn’t mean you’ll continue to have access if you leave that doctor’s practice.”
Prepare for Next Year
If you like your current doctor, you’ll want to keep him or her next year. When insurance enrollment season rolls around, call the doctor’s office and verify that the insurance options you’re considering are accepted before you pick one.
Since open enrollment only comes once a year for most consumers and usually only lasts a week or two, it’s hard to thoroughly vet insurance plans. It may be easiest for you to focus on just two things when you’re weighing your options: cost and network.
“I really think the most important part of choosing a plan is understanding the network,” says Poblete, who adds that, in general, a larger network of doctors and hospitals is better; if you ever find yourself stuck again, at least you’ll have a variety of new doctors to choose from.
But you also have to consider the cost of the plan. If keeping your doctor will double or triple your monthly premiums, will it be worth it?
“Try and assess your health needs for the next year, as much as possible, to know which plan is really worth it for you,” Poblete says. “It’s a very individual decision.”
[See: 10 Lessons From Empowered Patients.]
If you anticipate needing a lot of medical care, perhaps due to a chronic condition or a pregnancy, a plan with higher premiums and lower out-of-pocket costs might deliver the best value. Or if you’re relatively healthy and don’t anticipate needing many medical services, a lower-cost plan with less coverage may be right for you.
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What to Do When Your Doctor Leaves Your Health Plan originally appeared on usnews.com
null: This article was originally published on July 20, 2015.
