What to Do When Your Doctor Leaves Your Health Plan

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.

[Read: 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 founder 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.

[Read: What’s Medicare Supplement Insurance?]

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 22 million seniors who have Medicare Advantage plans, private alternatives to government-run Medicare: Those with these insurance policies can, under certain circumstances, leave their plans mid-year if their doctors do. There also is the Medicare Advantage Open Enrollment Period which runs from Jan. 1 through March 31. This enrollment period, which began in 2019, allows you to switch Advantage plans or go back to original Medicare. You can switch plans during the Annual Open Enrollment period for Medicare, Oct. 15 to Dec. 7, as well.

[Read: How to Make Health Insurance More Affordable.]

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, which 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.

More from U.S. News

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5 Steps for Picking a Medicare Plan

What to Do When Your Doctor Leaves Your Health Plan originally appeared on usnews.com

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