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Insights:
Your health insurance company may temporarily let you stay with your doctor if the provider is no longer considered in-network if you’re already receiving treatment for specific health issues.
What happens if your employer changes health insurance plans – or your doctor leaves your health plan’s network when you’re being treated for a medical condition?
Thanks to the transition of care and continuity of care, if you take the proper steps, chances are you can continue seeing your doctor, at least for a period. Your new health plan should treat these remaining medical bills as if you received in-network care.
The rules for both private health insurance plans and Medicare Advantage plans are similar regarding the transition of care and continuity of care. With Original Medicare, you typically can choose to see any doctor enrolled in Medicare.
Key Takeaways
The transition of care allows you to continue to receive services for specific medical and behavioral conditions even when health care providers aren’t in your plan’s network. You receive this care at in-network coverage levels.
Health insurance companies are most likely to grant this type of coverage if you’re finishing up care with a doctor who was in-network in your previous plan, but is out-of-network in a new plan, says Cindy Rigot, a patient advocate and owner of Re: Assured Advocacy in Denver.
An example might be if a patient had an appendix removed and the insurance changed right after the procedure. If the patient needs a follow-up appointment with a now out-of-network surgeon, the insurer might agree to cover the cost with in-network rates. If not, the insurer would pay out-of-network rates and the patient would have to pick up more of the bill.
“I think they’re trying to say to people, ‘Hey, if you’re in the middle of something, we’ll work with you,’ depending on the situation,” Rigot says. “So, you’re able to finish out whatever you are doing.”
The period when you can receive such care is temporary, lasting only until you’re able to find an in-network doctor or facility that’s able to provide similar care.
Typically, there are strict rules around how this process works. For example, at Cigna, you must apply for the transition of care when you enroll in a plan or change your Cigna medical plan. An application must take place no longer than 30 days from your coverage’s effective date.
Rigot says patients shouldn’t expect to have out-of-network visits covered over a long period. She notes that covering out-of-network care can be more expensive for insurance companies and insurers are more likely to “err on the side of what is financially advantageous for them.”
“I think when push comes to shove, they’re going to push people to go with the in-network folks,” Rigot says.
Continuity of care allows you to be treated at in-network coverage levels for specific medical and behavioral conditions even if a health care provider leaves your plan’s network.
This care may be granted only for a temporary period. You typically must be able to show a good reason for this request.
However, Rigot says there may be situations in which health insurers will grant the exception.
“If they see a situation where they think someone’s getting treatment from a really specialized physician and they maybe don’t have one in-network, they’ll probably let them continue,” she says.
Take these steps if you want to continue treatments with your doctor who is no longer considered in-network.
Your insurer might request additional information before approving a transition-of-care request.
“They might say, ‘We need to hear from your doctor, or we need clinical notes, your medical records and things like that,” Rigot says.
Your health insurance company is likely to ask your doctor to sign a transition of care request. It’s important that you follow these steps before you continue your treatment.
It may take some time to get approval, so be sure to allow for that. Apply for the transition of care as soon as you can.
Ask your doctors to go to bat for you if you want to continue receiving care from them, says Martin Rosen, executive vice president of Health Advocate in Plymouth Meeting, Pennsylvania, a health care advocacy and assistance company.
“The reality is that expertise really matters,” Rosen says.
Having your doctor explain to your health insurance company why you need to stay under his or her care is better than trying to do it yourself, he says.
“Most physicians are more than aware and understand this challenge,” Rosen says. “They have lots of experience with it.”
Also, you’re more likely to win the battle if your case is well-documented and you’re seeking benefits to which you would be entitled had your plan not changed, says Rosen.
For example, Rosen says most health insurance companies allow women in their third trimester to continue to see the provider with whom they started.
“If your obstetrician is not in your new network, the insurance company will likely make arrangements for you in large part because of the general view that it would be deleterious to the health of the mother if you didn’t continue with the same care,” Rosen says.
Rigot agrees that a doctor’s testimony can make a big difference in getting your request approved.
“If you can get your physician who’s treating you to write a compelling argument as to why you should be able to continue treatment with them, I think it’s definitely worth a shot,” she says.
There is no guarantee a physician will do so, but it’s still worth asking.
“What I always say to people is ‘The answer’s always ‘no’ unless you ask,’” Rigot says.
The amount of time granted to you to find a new in-network health care provider may vary by the health insurance company.
Cigna says that if transitioning to an in-network provider is deemed “not recommended or safe” for conditions that qualify, you will have a specific period – usually 90 days – in which you can use out-of-network services for that condition.
Aetna also says the transition-of-care period usually lasts 90 days, although this can vary.
With the transition of care and continuity of care, you might be able to see your doctor even if there are substantial changes to your health plan or your doctor’s participation in the plan.
For example, if you’re five months pregnant and your obstetrician leaves your health plan’s network, continuity of care might allow you to continue to see your doctor until you deliver and for any post-pregnancy follow-up, you need.
Rigot says it’s always worth asking if your insurance company will consider covering your out-of-network visits to a doctor, even if it’s for a short time.
“Don’t just roll over because they are going to try to get you to go with one of the network people,” Rigot says. “If you push back, you’re more likely to get what you want.”
Trying to get your health insurer to cover out-of-network visits without a compelling reason is difficult, if not impossible.
“They really want you to use those in-network physicians because they’ve negotiated those lower rates,” Rigot says.
In fact, she says that if you have a doctor you really like, a better approach might be to try to convince your doctor to join your new health insurance plan’s network.
“From a business perspective, if you’re a primary care physician, you want to be part of enough networks that you have enough patients,” Rigot says. “But you don’t want to join networks that are not reimbursing you well. So, it’s kind of a puzzle.”
