770-449-7369 / Fax: 770-449-1093 info@cdainc.net

 

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You took the time to properly shop your health insurance. You checked the provider directory, the approved drug list, the benefits and the premiums. So you’re set, right? Well, maybe not.

Providers can decide to leave networks at any time. Your doctors may decide to leave traditional fee-based private practices and enter into concierge arrangements where they charge a “membership fee” to access their services. In order to continue to see them you will need to pay an annual fee.

Others may sell their practices to hospital chains and become part of much larger provider systems. Beware the potential increased charges when billing comes through a hospital system. The office visit copay you are accustomed to paying may now be only a small part of the total cost of your visit.

Some providers elect to sell their practices and go to work in completely different settings. Finding your providers may take a while after this type of transition since the new ownership may not tell you where your provider went. Remember, they need to retain as many patients as possible to make their purchase worthwhile.

Certain providers continue to appear in your carrier’s directory, yet when you try to set an appointment you are told that they do not provide services to “Marketplace” contracts. This has proven to be the most confusing access issue since the start of the Affordable Care Act Marketplace plans. We have been told that providers have the option of signing either on-exchange or off-exchange contracts (or both) with the insurance networks. We have also been told that providers cannot pick and choose which contracts they will service. It is hard to tell which statement is true. All we know is that at the time that an individual needs to see a doctor it is not good to discover that there is a participation problem.

Our suggestion: before enrolling in a plan contact your providers’ insurance departments and ask if they are “participating providers” in the particular network you are considering. As you set visits later in the year verify each time that things have not changed. You may still have an unpleasant surprise if your doctors change their decisions, but at least you will go into your plan with the most updated information possible. Also, by asking for updates each time you access care you will not be blind-sided by unexpected bills for which you will be totally responsible.

Czajkowski Dumpel & Associates, Inc. is here to help you make sense of it all!