You’ve just found out that you will need to switch health insurance. Maybe it’s open enrollment time. Maybe your COBRA coverage is ending. You’re in the middle of treatment for a serious condition and you’ve looked at the provider directory, and surprise! – your specialist isn’t listed. Now what?
“Continuity of Care” is an advocacy strategy to maintain your providers and maximize your benefits.
Transition to a new health plan restarts the meter for your deductible and co-insurance. It can also force a change in doctors who are no longer considered in-network. If you’re relatively healthy, selecting a new provider, even a primary care physician, may be annoying. However, if you have complicated cancer, heart disease, diabetes or an acute condition, the stakes are much higher. You’re now facing sticker shock and possibly losing trusted providers on your treatment team. You may have upcoming services that can’t be rearranged. Staying with your providers may mean thousands of dollars out-of-pocket. Is it possible to keep the doctors and benefits you already have?
Understand Your Rights and Options
Officially, continuity of care is “the process by which the patient and his/her physician-led care team are cooperatively involved in ongoing health care management toward the shared goal of high quality, cost-effective medical care” (aafp.org). Sounds good in theory. Then reality kicks in about how to pay for services within our complicated, fragmented insurance system.
The Affordable Care Act brought changes, including defining continuity of care as ensuring emergency care. Federal rules were designed to ensure that consumers in the middle of an active course of treatment aren’t left in the lurch if their doctor or hospital is terminated from their health plan’s network.
Continue Care with Your Prior Doctor
Can you get around this barrier? It’s possible with good planning. Exceptions are made by insurance companies based on comprehensive, carefully prepared stories. You will need to prepare paperwork, balance the timing, and evaluate the financial risk that a concession won’t be allowed.
Factors that might apply:
- There are no specialists in the new network with similar licensure, accreditation or training.
- Providers offered on the network panel don’t have the same type of experience or clinical outcomes for your condition.
- You have an upcoming surgery/procedure that would have to be cancelled or delayed due to the change in providers or facilities, raising quality of care concerns.
- You have extensive documentation, including a letter from your prior doctor, that her/his expertise is necessary to maintain your health. Gather your medical records. Make sure you list and understand all of the procedures and services, so that staff reviewing your request can compare “apples-to-apples.”
- If your benefits are being reduced, try to avoid balance billing for non-network care. The health plan can set up agreements with providers to ensure that claims be processed as in-network.
What Else Should I Know?
Ideally, get approval before your new insurance starts. Ask for an urgent review through the case management or appeals department. You can file an appeal to reprocess claims after the services are completed, however getting approval beforehand is better.
Once you get a decision, which should always be in writing, read the fine print. Approval may just be for office visit consultations and nothing else. Imaging services such as MRI and CT scans may not be included. These kinds of tests can be done in-network, with follow-up interpretation done out-of-network. Approval to see your previous providers may only be allowed for up to 60-90 days, especially if you have an individual policy. Employer group policies are typically more generous.
If you’ve been fortunate to have access to a large provider network and think “this won’t happen to me” – think again. Increasingly consumers have to switch plans every year; networks are shrinking due to organizational and financial incentives.
Three Important Tips
- Plan ahead as possible. Ensuring continuity of care will take time and cause stress.
- Talk to your current health care providers as soon as you know your insurance will be changing.
- Submit a request to the insurer to review your case – often there is a form accessible on the member portal (health plan website).
- Read your benefits booklet, sometimes called an “Evidence of Coverage.” It may be available online on the health plan website. This summary will help you understand the policies and process to request exceptions and adjustments.
- Your State Department of Insurance has information and resources to help with questions and complaints about insurance plans. In WA State, look at the Office of the Insurance Commissioner website.