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What Can I Do if My Doctor Goes in and out of Network from One Year to the Next?

Doctor Leaves the network healthplan

Finding a good doctor often feels like a lottery win, especially if you’ve had a less-than-stellar experience in the past. Their medical knowledge may be sound, but the care you receive leaves you avoiding all but your annual wellness appointment. If that experience sounds familiar, learning that a great doctor left your network or Doctor leaves the network health plan can be very disappointing.

This can be especially challenging for patients with chronic conditions, or who underwent treatment for a serious illness, such as cancer, and who still receive follow-up care. For these patients, their history with the doctor who treated them throughout their illness makes starting over with someone new feel overwhelming.

Unless your doctor leaves your network shortly before open enrollment, your choices are limited, but there are options. We discuss what you can do below.

Paying Out-of-pocket

Your first option is to remain with your doctor and pay out-of-pocket for services. Most people do not have the financial resources to manage this option, but if you do, your doctor may offer a discount to patients who pay out-of-pocket. Many doctors offer these patients reduced fees, as the provider saves time and money when patient care doesn’t include the administrative tasks that come with an insurance carrier.

Continuity of Care

Some states have legislation called “continuity of care” that allows patients with certain conditions to continue receiving coverage for care from their doctor, even if that doctor no longer works within the patient’s network. Guidelines, such as covered conditions and length of coverage, vary by state. For example, some states may cover the remainder of a pregnancy or course of treatment. Alternatively, some may impose time limits, such as 90 days, that allow the patient to find a new doctor within his or her network.

Medicare Advantage Options

For the most part, Medicare Advantage beneficiaries remain in their plan for the calendar year, only making changes during the Annual Open Enrollment Period. The program offers allowances when a network change poses the potential to affect current plan enrollees. If your situation meets those criteria, the Centers for Medicare & Medicaid Services grants a 90-day enrollment period, allowing you to either join traditional Medicare or choose another Medicare Advantage plan with a provider network that includes your chosen physician.

Determination is on a case-by-case basis and considers a number of factors, including the plan’s service area size, whether advance notice accompanied the change, and at what point during the plan year the change occurred. Upon reaching its decision, Medicare notifies the plan, which in turn notifies its members.

Changing Doctors

You must be proactive and take control of your medical care, especially if you choose to change doctors. As soon as you learn your doctor is leaving your network, ask for a referral. If this is a doctor you trust, it is likely that he or she has a trustworthy referral to offer you. Ideally, you want more than one referral. This is especially important with narrow networks.

Also remember that, while you may have been referred to a new doctor, they may not be available on your network either. Verify whether the provider accepts your plan when you contact your potential new doctor. In addition, make sure the doctor’s affiliations, such as hospitals, are within your network.

To ensure you continue receiving the best care, ask your current doctor to communicate with your new provider regarding your care, and to transfer your medical records. Coordinating your care during this transition helps promote continuity of care and can give you the best possible outcome.

Be an Informed Consumer

As with everything healthcare related, be an informed consumer and take charge of your medical care. Carefully research your options during open enrollment, paying special attention to what best fits your unique needs. If you have a chronic condition, or underwent lengthy treatment for which you still receive follow-up care, consider how you will be affected if your doctor leaves your network. If you felt your heart rate increase just by thinking about this, look into plans that allow you to see an out-of-network provider.

Carefully review the differences between traditional Medicare and Medicare Advantage plans, as well. Coverage varies drastically from plan to plan; be sure to look past the price tag to choose the best plan for your needs.

In the end, you are the best advocate for your health. Take the time to research your options and make the right decision for you.

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