March 7, 2014
One challenge for patients enrolling and using health insurance on
the Affordable Care Act’s (ACA’s) health care marketplace is verifying whether
they really can see their doctor under the plan. And then what can the patient
do if he or she discovers the doctor is not on his or her health plan?
This week’s installment of Texas Medical
Association’s (TMA’s) “Hey, Doc” weekly education campaign offers some
out TMA’s video series, this week’s “Hey, Doc”
video, and a lot more information at MeAndMyDoctor.com and HeyDoc.texmed.org.
week of “Hey, Doc” education programming
How do I
find out if my doctor is on my insurance plan’s list? What should I do if I
thought my doctor was included, but really isn't?
not sure if your doctor participates in your insurance plan, there are few ways
to find out.
Marketplace rules require plans to publish an online directory of
participating doctors on Healthcare.gov. It’s
important to check those lists before you buy insurance to find out if your
doctor is in the plan you want. You also can call your
insurance company to check if your doctor is in the plan. Or, the
information might be included in the welcome packet you got when you first
You might have heard about some confusion over whether the insurance plan
lists online are up to date. So if you aren’t sure, call your doctor directly
to find out if he or she is participating in the plan you choose.
If your current doctor is not in your plan, you have a few options:
- If you decide to keep your doctor and he or
she is not in your plan, you may have to pay the full cost of your medical
bills, since seeking “out-of-network” care means you’re responsible for more of
- You can choose another doctor within your
- Or, even if your coverage already started
and you paid your premium, the federal government recently said that you might
be able to pick another plan with your doctor, as long as the plan is with the
same insurance company and in the same “metal” level as the one you signed up
for in the first place. (See “What different kinds of
insurance can I buy?”) You must contact your insurance company to make
the switch, and you most likely have to do this before March 31. Otherwise,
you’ll have to wait until the next sign-up period in the fall. (See “I haven’t signed up yet. Is it
And if you do decide to switch, be sure to ask your doctor first which
plans he or she takes.
find the specialist I need on my insurance plan’s list of doctors. What should
Remember that insurance plans in the marketplace must sign up enough
doctors, hospitals, pharmacies, and other providers to make sure patients can
get medical care. (See “Who will take care of me? What
are the networks?”) When you don’t have a choice and your plan’s
network doesn’t include the type of specialist you need, you can see a doctor
that’s not on your plan. But your health plan can’t charge you more than you
would pay if that doctor actually was on your current insurance plan.
The same thing applies if you have to get emergency care out of network.
If it’s not an emergency, be sure to call your insurance company ahead of time
to arrange to see an out-of-network specialist.
TMA is the largest state medical society in the nation,
representing more than 47,000 physician and medical student members. It is
located in Austin and has 112 component county medical societies around the
state. TMA’s key objective since 1853 is to improve the health of all Texans.
Contact: Pam Udall
cell: (512) 413-6807
Contact: Brent Annear
phone: (512) 370-1381
cell: (512) 656-7320
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Check out MeAndMyDoctor.com for interesting and timely news on health care issues and policy.