What to Do When Your Doctor Leaves Your Health Plan

“Doctors are professionals just like the rest of us. They move, they retire and sometimes they just can’t work with an insurer anymore for various reasons.”


When you have a good relationship with your doctor, it’s almost like magic – especially if you’ve ever had a doctor you’ve disliked. After all, a good doctor-patient relationship can do wonders for the quality of your health care. You’re more likely to be open and candid, and the doctor is more likely to listen closely and provide better care.

That’s why it can be so disappointing to find that your doctor is no longer in your network, meaning your health insurance company no longer covers your visits, or covers them at a lower level. Although most people would love to stick with a trusted provider, out-of-network doctors’ fees are often too steep to pay out of pocket. For example, a 45-minute visit to a doctor you’ve already seen can cost $300 if you’re paying cash, according to Fair Health Consumer, a website that helps patients estimate health costs.

That’s a steep price to pay for loyalty, but you can’t switch to an insurance policy that does cover your doctor until Open Enrollment later in the year. That is, unless your employer plan offers mid-year changes (very rare) or you experience certain life events such as marriage, divorce or a new job.

Why Does This Happen?

It’s not uncommon for doctors to enter and leave insurance networks. “Doctors are professionals just like the rest of us. They move, they retire and sometimes they just can’t work with an insurer anymore for various reasons,” says Sally Poblete, a health insurance expert and CEO of Wellthie, a technology company that helps consumers make health insurance decisions.

When your doctor does drop out of your network , you’ll probably be warned. “Most doctors inform their patients ahead of such a change so they have time to plan,” says Poblete, but neither doctors nor insurers are mandated to do so.

That means you might get a nice letter in the mail informing you of an upcoming change – or a bill after services are rendered for an amount way higher than your normal Copay or coinsurance. Either way, here’s what to do.

Find Out if You’re Protected

If you live in California or Massachusetts, you may be able to keep your doctor – at least for a little while – under a continuity of care clause. “If you have something like a pregnancy or an acute condition, continuity of care allows you to see your doctor until it’s over,” Poblete says. Under these clauses, you’ll continue paying the same copays and fees for your care until the baby is born or the condition resolves, but then you’ll need to find a new provider.

Continuity of care is also available in some insurance plans without being required by law, Poblete says. In these cases, patients with serious chronic conditions or terminal illnesses may also keep their providers for up to 12 months in order to make a safe switch.

And there’s good news for beneficiaries of Medicare Advantage plans, which are private alternatives to government-run Medicare. People using these insurance policies, which cover more than 16 million seniors nationwide, can leave their plans if their doctors do.

According to the updated Centers for Medicare and Medicaid Services guidebook, patients qualify to switch plans midyear if a network change is “considered significant based on the [effect] or potential to affect current plan enrollees.”

Medicare Advantage patients whose doctors leave their plans have three months to switch to another Medicare Advantage plan or traditional, government-run Medicare. In this case, your insurance provider, not your doctor, is responsible for informing you of the change.

Ask for a Referral

Everyone not living in California or Massachusetts or on Medicare Advantage is left with just two options: pay more to keep your doctor until open enrollment comes around again, or switch physicians. “If you like your doctor, call and ask for a referral to another physician,” Poblete says.

Doctors have different methods and philosophies of care, and are likely to refer you to someone with similar values – such as preferring lifestyle changes to medication increases or frequent phone follow-ups. If you like something specific about your doctor, say so when asking for the referral.

Negotiate When Overbilled

If you find out that your doctor left your network after services are rendered, you can probably negotiate with the doctor’s office, or with your insurance provider, to waive your portion of the charge.Medical bills large and small are negotiable, and it’s even easier if you weren’t informed of a change in your care or policy.

Start by explaining the problem to your doctor’s billing staff. Ask them to work with you on the price or waive it completely if it was a mistake. If that doesn’t work, call your health insurer’s customer service line and discuss your options for coverage – they may pay a bill if you weren’t given notice of the change.

Some states do have protections for patients who are caught in disputes between providers and insurers. Poblete recommends contacting your state’s insurance commissioner to find out if any apply to you.

Prepare for Next Year

If you like your current doctor, you’ll want to keep him or her next year. When insurance enrollment season rolls around, call the doctor’s office and verify that the insurance options you’re considering are accepted before you pick one.

Since Open Enrollment  only comes once a year for most consumers and usually only lasts a week or two, it’s hard to thoroughly vet insurance plans. It may be easiest for you to focus on just two things when you’re weighing your options: cost and network.

“I really think the most important part of choosing a plan is understanding the network,” says Poblete, who adds that, in general, a larger network of doctors and hospitals is better; if you ever find yourself stuck again, at least you’ll have a variety of new doctors to choose from.

But you also have to consider the cost of the plan. If keeping your doctor will double or triple your monthly premiums, will it be worth it?

“Try and assess your health needs for the next year, as much as possible, to know which plan is really worth it for you,” Poblete says. “It’s a very individual decision.”

If you anticipate needing a lot of medical care, perhaps due to a chronic condition or a pregnancy, a plan with higher premiums and lower out-of-pocket costs might deliver the best value. Or if you’re relatively healthy and don’t anticipate needing many medical services, a lower-cost plan with less coverage may be right for you.

If we can help in any way, please call us at 281-448-3040 or go to www.getagreatquote.com