QUESTION

I just found out that my provider is no longer in my network and I’ve been seeing him for years. What are my options?

Post enrollment issues | Individual Health Insurance
ANSWER

If it’s still open enrollment, November 1 to December 15, you can switch into another health plan that has your provider in the network. Information on how to make sure your provider is in a plan’s network can be found here. Unfortunately, if it’s past open enrollment, you can’t switch plans, but there are a few options.

First, depending on the plan rules, you may be able to see your provider, but at higher cost-sharing amounts. But note that the provider may be able to bill you the amount the insurer does not cover. The insurer is not required to count your out-of-network costs or provider charges for remaining amounts toward your plan’s annual out-of-pocket cost-sharing limit. Your plan’s Summary of Benefits and Coverage should include this information about out-of-network costs and an insurer must provide this document to you when you enroll, renew, upon request, or whenever there are any significant changes to your plan.

Second, you can file an appeal with the insurer to see if you can obtain care from your out-of-network provider at in-network cost-sharing. Finally, some states have “continuity of care” laws that require insurers to cover services at in-network cost-sharing for certain types of patients when a provider leaves the network. These laws vary by state, but if you live in a state with such a law, you may be able to get coverage for services from your provider for a limited period of time (usually up to 90 days). (45 C.F.R. § 147.200; 45 C.F.R. § 156.230; 45 C.F.R. § 147.136).

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Post enrollment issues