Before you signed up for a new health plan, you probably did your homework and checked that the doctor you had been seeing was in the plan's network. But when you call to make an appointment you learn the doctor no longer participates with your health plan. You feel betrayed. Maybe you even feel like there was a bait-and-switch scam. What's worse: "You're pretty much stuck until the next open enrollment," says Brian Luciani, CEO of Group Insurance Associates, a United Benefits Advisors partner firm, in Woodbridge, Conn. Unless you have a "qualifying life event," such as marriage, divorce, the birth of a child or change in job status, you must wait until the next open enrollment period to find another plan that includes your favorite doctors. You still may be able to see your doctor and get partially reimbursed if your health plan provides out-of-network coverage, says Carol Taylor, employee benefit adviser with D&S Agency in Roanoke, Va., also a UBA firm. If you have a preferred provider organization or point-of-service plan, you can generally see an out-of-network provider. However, expect to pay more in co-insurance when you go out of the network, Taylor says. In addition, you may be responsible for the difference between what the plan will pay for a covered service and what your doctor or health care provider charges. Here's more on using your health plan for doctors who don't take your insurance. If you have an HMO and it doesn't provide any out-of-network coverage, you'd have to foot the entire bill yourself. According to the Center on Health Insurance Reforms at Georgetown University's Health Policy Institute, since open enrollment for 2014 plans ended on March 31, some consumers are finding the networks they chose are changing or aren't as robust as they thought -- and consumers aren't happy about it.
Lisa Zamosky, author of "Healthcare, Insurance, and You: The Savvy Consumer," says she too is "hearing that consumers around the country are unhappy with the plans they bought because their networks are far smaller than they thought they were going to be."Doctors and hospitals are free to move in and out networks as they see fit, Zamosky explains. "That's not a function of the Affordable Care Act. That's the private, for-profit system and it was this way before the [Affordable Care Act]."
Fighting for the doctors you wantIf you're unhappy with the health insurance plan you chose, depending on where you live and the plan itself, all may not be lost, says Zamosky, who also writes a column on health insurance for the Los Angeles Times. Zamosky offers some strategies that are somewhat of a long shot but could be worth a try if you really want to continue to see the doctor or use the hospital you had been planning on. Check to be sure your plan's network is adequate. The rules can vary from state to state but in California, where Zamosky lives, health insurance plans must provide their policyholders with access to a primary care physician within 15 miles or 30 minutes of their home, she says. If you live in a more rural area, the plan has a little more flexibility. Also, you have to be able to get an appointment with a primary care doctor within 10 business days if it's not urgent and within 15 business days if it's a specialist. If you can't make an appointment with a doctor or specialist within that timeframe, you can insist your health insurance plan help you find someone who will see you. Check with your state insurance department to find out what the rules are for your state. Maybe your doctor isn't the only one to have dropped out of the insurer's network and the number of physicians accepting your plan is so limited that the plan can't meet the state's rules.
File an appeal. If you feel you have a legitimate need to continue care with the doctor you had been seeing, you can file an appeal with your insurance company -- and you should, Zamosky says. You have the right to two levels of appeal, internally with the insurance company and with a third party.Luciani adds that if you are in the middle of treatment for a disease such as cancer or are in the third trimester of pregnancy, you may be able to stay with your doctors even if they drop out of the network under "continuity of care" laws in your state. "You may be able to make a case for seeing your doctors if it would be a real hardship to switch and if the doctors you're seeing agree to accept what the health plan will pay," he says. Late last year, the Department of Health and Human Services strongly encouraged plans operating in the health insurance marketplace to allow their subscribers to get out-of-network care at in-network rates if the plan's provider network was out-of-date at the time they enrolled.