What happens if your doctor leaves your plan's network in the middle of the year?
It’s an unfortunate scenario: your trusted doctor, the one you’ve built a relationship with and rely on for care, is suddenly no longer part of your health insurance network. This can happen for a variety of reasons, such as contract disputes, changes in practice affiliations, or shifts in the insurance company’s network. Whatever the cause, you may be wondering what steps to take if your doctor is leaving the network mid-plan year.
Here’s a breakdown of your options and the actions you can take:
In this article
Understand why the change happened
First, it’s important to find out why your doctor is leaving the network. Reach out to your doctor’s office and ask if they have received any formal communication about the change. Some doctors leave networks due to disagreements over reimbursement rates or administrative issues, while others might join a different network or shift their practice focus.
Additionally, check with your insurance provider. They may have information about the network change, and understanding the details can help you make more informed decisions and better guide your next steps.
Review your health insurance plan's network polices
Insurance companies often provide details about how mid-year network changes work in their policies. Depending on the specifics of your plan, there may be protections in place if your doctor leaves the network. For instance, some plans offer a grace period, where you can continue seeing your doctor even after they’ve left the network.
In some cases, your insurer may also allow you to transition to a new doctor within the same network without affecting your coverage. Other plans may offer continuity of care for ongoing treatments if you’re in the middle of a course of care (e.g., for surgery, chemotherapy, etc.).
It’s crucial to review your health insurance plan’s documentation about your rights and options in this situation.
Understanding continuity of care options
Under the Affordable Care Act, health insurance companies are required to allow continuity of care if you are undergoing ongoing treatment with a provider who leaves the network mid-year. If you’re receiving long-term treatment or have a serious health condition, you may be eligible to continue seeing your doctor, even if they are no longer in-network.
For example:
- If you’re pregnant, insurers are generally required to cover prenatal and postnatal care through the end of your pregnancy.
- For active treatments like chemotherapy or physical therapy, your insurer may let you continue your treatment with the same doctor, even if they are out-of-network.
- For chronic conditions requiring specialized care, you may have the right to continue care with your current doctor for a set period, allowing time to transition to another provider.
Be sure to request written confirmation from your insurer regarding these options.
Look for a new in-network provider
If your doctor is definitely out of network, and continuity of care isn’t an option or you prefer a new doctor, start searching for an in-network provider.
- Contact your insurer: Ask for recommendations for doctors who specialize in your care and are in-network. Some insurers also have online directories of in-network doctors, which can make the search easier.
- Ask your current doctor for referrals: Your current doctor may be able to refer you to a trusted colleague within the same network, helping to maintain continuity in your care.
- Check online reviews: Patient feedback can help you evaluate potential new doctors, but always check their credentials and whether they accept your insurance.
Explore a Special Enrollment Period
If your doctor leaving the network has caused a significant disruption in your healthcare, you may be eligible for a Special Enrollment Period to switch plans. This option is available outside the usual open enrollment window, but only if certain criteria are met.
For example:
- If you lose access to your current doctor or specialist because of a network change, this may qualify as a “loss of coverage” and trigger a SEP.
- If you’re facing difficulties finding an in-network provider that fits your needs, this may also qualify you for a SEP.
Determining if you qualify for one of these, or other, SEPs is something that a broker will be able to help you with.
Appeal to your insurance company
If you’re unable to find a resolution with your insurance company, or are not satisfied with their options, you have the right to appeal the decision. Insurance companies are required to follow specific rules regarding network changes, so if you believe your options are unfair or insufficient, consider submitting an appeal.
You can read more about the appeal process and what steps to take first here. Also, feel free to reach out if you have any questions about this process; we are more than happy to help you with the process.
This appeal process may take some time, but if successful, it can help ensure you’re not left without the care you need.
Look into telemedicine options
If finding a local in-network doctor is a challenge, another option could be telemedicine. Many insurance companies now offer virtual doctor visits as part of their coverage, including access to specialists in different networks. While telemedicine might not replace in-person care entirely, it can be an interim solution for non-emergency consultations, prescriptions, or follow-up appointments.
Check if your insurer covers telemedicine and if it can bridge the gap while you transition to a new in-network doctor.
You can read more about telemedicine, what it covers, and how it works here.
Other options
If your doctor’s departure leaves you with significant disruption to your care, and you’re unable to find an acceptable solution through the actions above, you may need to explore the possibility of switching health insurance plans during the next open enrollment period.
- Employer-based plans: If you receive health insurance through your employer, check to see if you can switch to a different plan during the open enrollment period.
- Marketplace plans: If you’re on a marketplace plan, you can change plans during open enrollment, provided the plan offers your doctor or a suitable alternative.
Takeaways
When your doctor leaves your health insurance network mid-year, it can feel like a major disruption to your healthcare. However, there are multiple avenues you can explore to manage the change, including looking for continuity of care, finding a new in-network provider, appealing to your insurer, or even switching plans during a special enrollment period. Take proactive steps to understand your rights and options, and make sure you’re receiving the care you need while navigating these changes.
If you’re feeling overwhelmed or want to make sure you’re approaching the situation correctly, don’t hesitate to reach out to us for help navigating your options and rights.
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