What If My Doctor Doesn’t Take My Marketplace Health Insurance?

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 suggestions.

Check out TMA’s video series, this week’s “Hey, Doc” video, and a lot more information at MeAndMyDoctor.com and HeyDoc.texmed.org.

TMA’s 21st 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?

If you’re 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 enrolled. 

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 the bill. 
  • You can choose another doctor within your plan.  
  • 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 too late?”)   

And if you do decide to switch, be sure to ask your doctor first which plans he or she takes.

I can't find the specialist I need on my insurance plan’s list of doctors. What should I do?  

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. 

--30--

Contact: Pam Udall
phone:(512) 370-1382
cell: (512) 413-6807

Pam Udall  

Contact: Brent Annear
phone: (512) 370-1381
cell: (512) 656-7320

Brent Annear  

Click here to follow TMA on Twitter. Or visit TMA on Facebook. 

Check out  MeAndMyDoctor.com for interesting and timely news on health care issues and policy. 


Comment on this (Must be logged in to comment)

Add Comment

Text Only 2000 character limit

Looking for more?