Medicare Uncategorized Your Coverage Options

What to do if your in-network doctor goes out of network?

Written by Diane Archer

It used to be that our health care system valued continuity of care. Insurers covered care from virtually any doctor or hospital, and we could stick with our doctors over our lifetimes. And, that’s still the case with traditional Medicare. But, if you’re in a Medicare Advantage plan or virtually any other health plan, you are at risk of losing that continuity of care if your doctor pulls out of the network or you’re forced to switch plans. What can you do if your in-network doctor goes out of network mid-treatment?

When you’re mid-treatment, it can be critical to stick with the doctors who have been treating you. They know your condition through and through. They know which treatments work and which don’t. And, you and they have developed a bond, a trust, that can be as valuable as the medical treatments you’re receiving. But, the cost of out-of-network care from the doctors you know and trust, can be astronomical. So here’s what to do:

  • If you are enrolled in a Medicare Advantage plan, call your State Health Insurance Assistance Program for help. You can find the number online at www.eldercare.gov or by calling 1-800-677-1116. You may be able to get your health plan to continue to cover your care from the doctors who have been treating you. Also, the Centers for Medicare and Medicaid Services (CMS) may grant members of a Medicare Advantage plan the right to switch plans as a result of a “significant” change in a health plan’s provider network.  CMS does not define “significant.” But, according to Kaiser Health News, it has been granting this right to some health plan members who have seen changes in their provider networks.
  • If you are not yet enrolled in Medicare, contact your state department of health or department of insurance to find out your rights. Some employers and some state laws allow–or are considering allowing–people with chronic, acute or terminal conditions to stick with their doctors for as long as a year (and longer for terminally ill patients), even if their doctors are no longer in their networks. Their new health plans must cover care from their providers so long as those providers are willing to accept the health plans’ payment rates.

Here’s more from Just Care:

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