What If My ACA Marketplace Health Plan Excludes My Doctor?

Aug 27, 2014

Answers to Your Questions About the ACA Marketplace

It’s a dilemma: A patient enrolls in an Affordable Care Act (ACA) marketplace health plan under the assumption his or her doctor is included in the plan, but later discovers that is not the case. What now?

This week’s installment of Texas Medical Association’s (TMA’s) “Hey, Doc” education campaign offers some suggestions for Texans who face this challenge.

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 a few ways to find out.

1. Check the health plan physician list. 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.  
2. Call your insurance company to check if your doctor is in the plan. 
3. Review the information in the welcome packet you got when you first enrolled.   
4. Call your doctor’s office directly. 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 to find out if he or she is participating in the plan you chose.  

If your current doctor is not in your plan, you have a few options:  

• If you decide to keep your physician 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 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?”) But there was a March 31 deadline to make this switch. Since that date has passed, you’ll likely have to wait until the next open enrollment period starting Nov. 15, 2014, unless you meet exceptional circumstances. (See “I haven’t signed up yet. Is it too late?”)   

And if you CAN switch and you do decide to, 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, 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. 

Click here to watch a brief “Hey, Doc” video about what to do if your doctor is not on your insurance plan’s list of providers.

(Check out all of TMA’s “Hey, Doc” information series for answers to more ACA marketplace questions at MeAndMyDoctor.com and HeyDoc.texmed.org, and TMA’s YouTube channel.)

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