Haris Ashley
Changing insurance companies can affect whether you can continue seeing your primary care provider. If you switch to an insurance company that doesn't include your existing healthcare provider in its network, 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, you don't necessarily have to change doctors if you purchase a new health insurance plan. If you're shopping for health insurance, you can prioritise keeping your doctors and prescriptions. You can check if your doctors and prescriptions are available on a given plan using tools provided by healthcare.gov, state exchanges, and private exchanges.
| Characteristics | Values |
|---|---|
| Do I have to change doctors if I change insurance? | You don't necessarily have to change doctors if you change insurance. |
| How to check if my doctor is in-network with my new insurance plan? | Check with the new plan provider to see if your doctor is in-network. Many health insurance companies have websites that let you search for providers. |
| What if my doctor is not in-network? | A Preferred Provider Organization (PPO) plan allows patients to see out-of-network doctors, but it is more expensive. A Point-of-Service (POS) plan might also be an option, as it allows for out-of-network care with a referral from an in-network provider. |
| What is transition of care? | Transition of care allows you to temporarily see your current doctor in specific situations where ongoing care is needed. Your new insurance company will treat these bills as if you received in-network care. |
| How long can I benefit from the transition of care? | The period when you can receive such care is temporary and usually lasts a few weeks to several months. |
| How to get the transition of care request approved? | Submit a "transition of care request" signed by your doctor before the plan change is made. Your doctor can also help by explaining to your insurance company why you need to stay under their care. |
What You'll Learn
Check if your doctor is in-network
Changing insurance companies can affect whether you can continue seeing your primary care provider. If you want to stay with the same healthcare provider, it's best to find out which insurance policies your doctor accepts before switching to a new health insurance plan.
- Contact your new insurance company and ask for a list of in-network providers. You can then check this list to see if your doctor is included. Many health insurance companies have databases on their websites that allow you to search for your provider to see if they're in-network.
- Contact your doctor's office directly and ask if they accept your new insurance plan. Most receptionists and office professionals will know whether they're in-network.
- Ask your doctor for their tax identification number and then contact your insurance company to confirm whether your doctor is in-network for your specific plan.
- Check your insurance company's website to get an updated network list.
- Call your insurance company's member services team to get help with any questions about your plan. You can usually find their phone number on your health insurance member ID card.
- Ask your care provider. Your provider may be able to tell you if they take your insurance plan by looking at your health insurance card. However, it's always best to confirm with your insurance plan.
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Ask your doctor about insurance companies they work with
When you change your insurance, you may not have to change your doctor. It 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 doctor has a contract with your insurer to provide services for an approved amount. If your doctor isn't part of the network, they're known as an "out-of-network provider".
If you want to keep seeing your current doctor after changing insurance, you should ask them about which insurance companies and networks they work with. It's possible that your doctor works with multiple insurers or is part of multiple networks. This will give you an idea of the companies you could choose from when shopping for health insurance.
If your doctor is out-of-network with your new insurance, you may still be able to keep seeing them, but it will likely be more expensive. Preferred Provider Organization (PPO) plans allow you to see out-of-network doctors, but you'll usually have to pay the difference between the approved amount and what your doctor charges out of pocket. Point of Sale (POS) plans require you to choose an in-network primary care provider, but they will usually cover out-of-network services if referred by your in-network provider.
In some cases, your new insurance company may temporarily allow you to stay with your out-of-network doctor if you're already receiving treatment for specific health issues. This is known as "transition of care" and usually only applies for a limited time until you can find an in-network doctor.
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Consider a Preferred Provider Organization (PPO) plan
A Preferred Provider Organization (PPO) plan is a health insurance plan for individuals and families. It is a type of managed-care health insurance plan that offers a network of healthcare providers for your medical care. These providers have agreed to provide care to the plan members at a certain rate.
PPOs have networks of doctors, other healthcare providers, and hospitals. You pay less if you go to providers that belong to the plan's network. You can generally go to out-of-network providers for covered services, but you'll usually pay more.
PPO plans do not require you to choose a primary care physician (PCP) and do not require referrals. For example, if you already have a doctor you like, you can continue receiving care from that provider. If you need to see a specialist, you do not have to first consult with a PCP. No referrals are required for any doctor, specialist, or hospital.
PPO plans are more comprehensive in their coverage and offer a wider range of providers and services than HMOs. However, the costs associated with PPOs include higher insurance premiums, copays, and deductibles. Choosing between a PPO and an HMO generally involves weighing one's desire for greater accessibility to doctors and services versus the cost of the plan.
If you are eligible to enroll in Medicare, there are Medicare Advantage PPO plans available. A PPO is generally a good option if you want more control over your choices and don't mind paying more for that ability. It would be especially helpful if you travel a lot, since you would not need to see a primary care physician.
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Ask about cash payments
If you want to keep your doctor but change your insurance, you may be able to do so by asking about cash payments.
A small but growing number of doctors are ditching insurance companies and working directly with patients. This model is known as direct care or direct primary care. Patients pay an annual or monthly fee for access to their doctor, which covers most primary care procedures. This can include physicals, strep throat tests, EKGs, and stitches. Patients also get 24/7 access to their doctors, longer office visits, and same-day appointments.
The average monthly payment for direct primary care is $25 to $85, but some practices offer different membership levels. For example, at Dr. Carmela Mancini's practice in Massachusetts, the fee ranges from $30 per month for 18- to 21-year-olds to $125 per month for people 65 years or older.
If you can afford it, paying out of pocket with a discount from your doctor can allow you to keep the same doctor. However, it's important to note that cash payments usually won't count toward your deductible or out-of-pocket maximum.
If you're considering switching to a direct primary care model, be aware that not all doctors accept cash payments, and you may need to be persistent in your requests. Additionally, this model may not be feasible for those on Medicaid or with other financial constraints.
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Submit a transition of care request
If you are already receiving treatment for specific health issues and your doctor is no longer considered in-network, your health insurance company may temporarily let you stay with your doctor. This is known as a "transition of care" and allows you to continue receiving services for specific medical and behavioral conditions, even if your healthcare provider is not in your plan's network.
To continue treatments with your doctor, you must submit a "transition of care request" signed by your doctor before the plan change is made. The form must be signed by the person requesting the transition of care. If the patient is a minor, a guardian's signature is required.
Each insurance company has its own eligibility criteria for transition of care requests. For example, at Cigna, you must apply for the transition of care when you enroll in a plan or change your Cigna medical plan. The application must take place no later than 30 days from your coverage's effective date. Sanford Health Plan also requires that you apply for a transition of care no later than 30 days after your plan's start date.
Situations that may qualify for transition of care include:
- Chemotherapy
- Radiation
- Surgeries performed in stages
- Post-surgical care
- Organ or bone marrow transplant
- High-risk pregnancies
- Substance abuse treatment
- Major surgery
Your insurance company must approve treatments before they are rendered, so it is important to submit a transition of care request as soon as possible. The approval process can take time.
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Frequently asked questions
Whether you can keep your doctor depends on whether they are part of your new insurer's network. Doctors who are part of an insurer's network are known as "in-network providers", whereas doctors who are not part of the network are known as "out-of-network providers". If your doctor is out-of-network, your insurer may not cover their treatment or services, and you may have to pay out of pocket.
You can contact your new health insurance company and ask for a list of in-network providers. You can then check if your doctor is on that list. Many insurance companies also have databases on their websites that allow you to search for your doctor to see if they are in-network. Alternatively, you could try contacting your doctor's office directly to ask if they accept your new insurance plan.
You may be able to continue seeing an out-of-network doctor by purchasing a Preferred Provider Organization (PPO) plan. PPO plans have a list of preferred providers, but they also allow enrollees to use out-of-network providers. However, seeing an out-of-network doctor on a PPO plan will be more expensive than using an in-network provider. Another option is to purchase a Point of Sale (POS) plan, which requires you to choose an in-network primary care provider. Your insurer will usually cover out-of-network services if referred by your in-network provider.
Many insurers allow enrollees to continue using an out-of-network doctor temporarily after switching 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, and they also impose eligibility criteria for receiving out-of-network coverage.
