Getting a letter saying your doctor or hospital will no longer be in your insurance network is unsettling, particularly if you have been with the same cardiologist for years.
Here is what it actually means, and what to do about it, in order.
First, understand what happened
Insurers and health systems sign contracts that set what the insurer pays. Those contracts come up for renewal, and occasionally the two sides cannot agree. When that happens, the provider leaves that insurer's network.
It is a commercial disagreement between two organizations. It is not a judgment on your doctor, and it does not mean you have done anything wrong. It also sometimes gets resolved before the deadline, which is why step two matters.
Step 1: Check it yourself rather than relying on the letter
Call the number on the back of your insurance card and ask directly: is this doctor, and this facility, in network for my specific plan, and from what date does that change?
Plan names matter. Two plans from the same insurer can have completely different networks. Ask for a reference number for the call and write down who you spoke to.
Step 2: Ask about continuity of care
This is the part most people do not know about, and it is worth asking even if nobody has mentioned it.
Under federal rules that apply to most employer and individual health plans, certain patients can keep being treated at in-network rates for up to 90 days after a provider leaves the network. You generally have to qualify as a continuing care patient, which includes people who are:
- Being treated for a serious and complex condition
- Receiving treatment for a chronic condition that needs prolonged specialized care
- In hospital or receiving inpatient care
- Scheduled for non-elective surgery, or recovering from one
- Pregnant and receiving related care
- Receiving end-of-life care
Your plan is required to tell you about this and to let you choose it. If nobody has, ask. Medicare Advantage plans have their own process, so if you are on one, ask your plan specifically what it offers.
Ninety days is not forever, but it is enough time to finish a course of treatment or to move carefully rather than in a hurry.
Step 3: Decide whether to change plan or change doctor
There are only two ways out, and which is open to you depends on your situation.
If you are on Medicare Advantage, the annual enrollment period runs from 15 October to 7 December each year, and that is when you can change plans for the following year. If you want help comparing, Florida's free Medicare counseling service and 1-800-MEDICARE can both talk it through with you. We cannot advise you on which plan to choose, and you should be wary of anyone who offers to.
If you have an employer plan, your options usually open at your company's annual enrollment. Your HR department can tell you when that is.
Or you change to an in-network doctor, which for many people is the simpler path, particularly if your care is stable.
Step 4: Move your records properly
Your medical records are yours. A practice must provide them on request, though it may charge a reasonable fee for copies.
- Ask for your records in writing, and ask for actual images on a disc for any echocardiogram, CT or angiogram, not just the written reports. Images are far more useful to a new cardiologist and save you repeating tests.
- Ask for your most recent clinic letters, test results and the full medication list.
- Give the new practice the old practice's details and let them request directly. It is usually faster.
- Do not stop any medication while this is going on. Make sure you have enough to cover the gap, and ask for a refill before you need it.
Step 5: Ask the new practice the right questions
- Are you in network for my specific plan, and can you check it before I come in?
- How soon can I be seen?
- Will you get my records, or do I need to?
- Who will I actually see, and will it be the same person each time?
- If I need a procedure, do you perform it, or will I be sent elsewhere?
Quick answers
Can I keep seeing my doctor and pay the difference?
Sometimes, but it is usually a lot more than people expect, and out-of-network care often does not count towards your deductible in the same way. Ask your plan for the specific figures before deciding.
What if I am in the middle of treatment?
That is exactly what continuity of care exists for. Call your plan and ask about it before you do anything else.
Will I lose my place if I need a procedure?
Not necessarily. Tell any new practice what is planned and when, and ask how quickly they can pick it up.
How quickly can I get a new cardiologist?
Faster than most people assume. We can usually see new patients within 1 to 2 days, pending insurance approval.
If you need an in-network cardiologist in Southwest Florida
We are a private cardiology practice at 13411 Parker Commons Blvd, Fort Myers, on the north side of Daniels Parkway, caring for people across Lee and Charlotte counties, including Cape Coral, North Fort Myers, Lehigh Acres and Punta Gorda.
Call (239) 415-4900 and we will check your plan with you before you come in. You can see the plans we participate in on our insurance page.
This page is general information about insurance, not advice about your own plan or your own care. Always confirm your coverage directly with your insurer.
Source: Centers for Medicare & Medicaid Services, No Surprises Act consumer protections.
