Do I Have to Change Doctors If I Change Insurance?

by Team eLocal
Middle-aged bearded patient having consultation with highly professional physician at modern office, they discussing diagnosis and possible treatment

The American health insurance system is, well, complicated. Switching insurance companies can affect whether you can continue seeing your primary care provider.

Whether your existing doctor accepts your insurance plan should be one of the first questions you should ask before purchasing a new health insurance plan.

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If My Insurance Plan Changes, Will I Have to Change Healthcare Providers?

Whether you can keep your current healthcare provider depends on whether your doctor is part of your new insurer's network. Doctors who are part of an insurer's network are known as in-network providers. This means your provider has a contract with your insurer to provide services for an approved amount. If your provider isn't part of the network, they're known as an out-of-network provider.

Issues can arise when you switch to an insurance company that doesn't include your existing healthcare provider in its network. In this situation, your insurer may not cover treatment or services received from your doctor, and you may have to pay for care out of pocket or change providers. However, there are some exceptions to this rule.

PPO Plans

Preferred Provider Organization (PPO) plans have a list of preferred providers, but they also allow enrollees to use out-of-network providers. Therefore, you can continue to see your doctor, even if they're not a preferred provider.

However, seeing an out-of-network doctor on a PPO plan is more expensive than using an in-network provider. Insurers set an approved amount for specific treatments and services, and out-of-network doctors can charge more than the approved amount. You'll usually pay the difference between the approved amount and what your doctor charges out of pocket. In this situation, using an out-of-network doctor may become prohibitively expensive, especially if you require regular care.

POS Plans

Point of Sale (POS) health insurance plans require you to choose an in-network primary care provider. However, your insurer will usually cover out-of-network services if referred by your in-network provider. Therefore, you may be able to keep seeing your preferred out-of-network specialist by asking your in-network primary care provider to make a referral.

Transition of Care

Many insurers allow enrollees to continue using an out-of-network doctor temporarily after switching health insurance plans. This process is known as "transition of care" and usually applies if you require ongoing care and can't immediately locate or attend an in-network clinic.

Seeing an out-of-network doctor under a transition of care agreement often has the same out-of-pocket costs as seeing an in-network provider, but there are restrictions. Most insurers limit how long they'll cover out-of-network care, usually just a few weeks or months. Furthermore, insurers impose eligibility criteria to receive out-of-network coverage under transition of care. These criteria vary between insurance companies, but could include the following circumstances:

  • Newborn care
  • Antenatal care
  • Cancer treatment
  • Major surgery or organ transplant
  • End-of-life care
  • Substance abuse treatment

If you have no choice but to change insurance companies, your doctor can provide support to ensure you continue receiving the care you need. For example, you could ask your doctor to provide evidence that continuing to see them for a limited period under a transition of care agreement is medically necessary. Alternatively, your doctor may recommend a trustworthy in-network provider to take over your care.

How Do I Check If My Doctor Is In-Network With My New Insurance Plan?

Ideally, you should find out which insurance policies your doctor accepts before switching to a new health insurance plan if you want to stay with the same healthcare provider. Selecting a company that includes your doctor in its network can help ensure continuity of care.

Your new health insurance company can provide a list of in-network providers, and you can check the list to determine whether your doctor takes your insurance. Many health insurance companies have databases on their websites that allow you to search for your provider to see if they're in-network, making it quick and straightforward to determine whether your doctor is a preferred provider.

Alternatively, you could try contacting your doctor's office directly to ask if they accept your new health insurance plan. Generally, a doctor's receptionist will know which networks and plans the provider or office participates in.

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