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 January 15 in most states—you can try to 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, unless it is a situation covered by state or federal protections against such bills, including emergency care or an out-of-network provider at an in-network facility. 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, there are “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. In 2021, 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). You can contact your state’s Department of Insurance to find out if such protections apply to you. Beginning in 2022, some patients undergoing a course of care who are enrolled in an individual or group health plan will be eligible under new federal protections to temporarily pay only in-network cost sharing for their continuing treatment when their in-network provider becomes out-of-network in the middle of a plan year (unless the contract terminated due to failure to meet quality standards or for fraud). Coverage of transitional care is only available to patients for whom one of the following applies:

· Undergoing a course of treatment for a serious and complex condition (as defined by the new law) from the now out-of-network provider;

· Undergoing treatment for an existing pregnancy from the now out-of-network provider;

· Undergoing treatment for terminal illness from the now out-of-network provider;

· Undergoing a course of institutional or inpatient care from the now out-of-network provider; or

· Scheduled for a non-elective surgery, including receipt of postoperative care, from the now out-of-network provider

If you are in one of the situations mentioned above, your insurer or health plan should notify you of your ability to elect to receive transitional care from your current provider under the same terms and conditions that would have applied if the provider had remained in-network. The protection applies for up to 90 days after you receive notice of the change in your provider’s network status, or until the qualifying course of treatment with that provider ends (whichever occurs earlier).

(45 C.F.R. § 147.200; 45 C.F.R. § 156.230; 45 C.F.R. § 147.136; Consolidated Appropriations Act, 2021, Pub. L. No. 116-260, 134 Stat. 1182).

Individuals with no coverage
Individuals with coverage
Coverage for small employers
Post enrollment issues