What To Do If Your Doctor Stops Participating in Your Health Insurance Plan

Going to the doctor usually doesn’t allow for casual small talk, as you may only see them once a year. Often, you must explain your ailment quickly and succinctly. You also have to trust that your doctor has your best interests at heart and keeps your health information confidential. Having a good relationship with your doctor can help alleviate these issues and increase the quality of your health care.

But what happens if you have a good relationship with your doctor and then learn that they are no longer accepting your health insurance plan?

Fortunately, there are ways you can plan for this and methods to make a smooth transition to a new physician.

Why Doctors Stop Participating in Health Insurance Plans

Usually, doctors leave health insurance networks for typical reasons, such as retirement or moving geographic locations. They are professionals, and just as you probably have had to move for a new job, they do the same. Sometimes, their reasons may be somewhat more technical. For example, a doctor or the practice they work for may be unhappy with how the health insurance plan conducts business.

You may receive some warning that your doctor will no longer participate in your health insurance plan, but neither your doctor nor your health insurance provider is legally obligated to inform you ahead of time. Unfortunately, this can lead to unexpected medical bills.

What to Do If Your Doctor Stops Accepting Your Plan

If your doctor stops accepting your health insurance plan, you may have temporary continuity of care protection. This can enable you to retain the same level of care from your doctor for the same copays and fees on a temporary basis.

If you are a senior who participates in a Medicare Advantage plan, you have the option to leave your health care network if:

• your doctor does; and
• if the network change is, according to the Centers for Medicare and Medicaid Services guidebook, “considered significant based on the [effect] or potential to affect current plan enrollees.”

If you currently have coverage under a private plan and are considering switching, call your doctor’s office and ensure they are covered under the new plan you are considering.

Other Options

As it is important to maintain continuity of care, if you aren’t afforded temporary continuity of care protection and if you cannot switch health insurance plans to one that your provider will accept, you will have two options.

The first option is to explore paying privately for visits to your doctor, even if only for a short time to complete or continue a course of treatment until you can find a new doctor. Affordability will be an important concern. Sometimes, since you pay upfront and the doctor’s office doesn’t need to apply to a health insurance company for reimbursement, private pay is less costly than you may expect. However, sometimes it will be prohibitively costly, and you will need to explore the second option.

The second option is to ask your doctor to refer you to a provider who accepts your insurance. Since they know your health situation and needs best, they should be able to refer you to another doctor they think will be a good fit for you.

If you would like to speak with an experienced elder law attorney regarding your situation or have questions about something you have read, please do not hesitate to contact our office at 1 (800) 680-1717. We look forward to the opportunity to work with you.

Disclaimer: The information provided above is for general informational purposes only and is not legal advice.