Your rights when your health plan changes

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It’s possible that your employer changed health plans last year. If your family doctor wasn’t in the new HMO’s network of approved health care providers, you may have begrudgingly switched doctors.

But what if your employer changes plans again? Are you stuck back at square one, searching for yet another doctor, just when you were getting used to the new one you selected last year?

That depends on a number of factors, including where you live and your health status.

HMO coverage has driven provider switches

patient rights Years ago, employer-sponsored health insurance plans were fee-for-service arrangements. You chose any doctor or hospital you wished and the insurance policy paid for it. Managed care was developed to improve efficiency and control costs, and most plans now feature some form of managed care. These plans contract with networks of doctors, specialists and hospitals. If you use an out-of-network provider, you may not get the service fully or even partially covered — depending on the plan.

Your parents or grandparents may have had the same doctors for most of their adult lives. But in today’s system, changing health plans can mean changing provider networks. Since employers review health contracts annually, continuity is not always the case.

Changing doctors may not be a big deal if you’re healthy. But if you have cancer and your oncologist isn’t in the network, or if you’re pregnant and suddenly face changing obstetricians, switching providers could be a crisis. It could disrupt continuity of care, result in repeated tests, redundant medical records and a lack of understanding of your medical history.

Consumer protections vary when employer switches health insurance plans

John Metz, executive director and chairman of JustHealth, a patient advocacy service based in Santa Rosa, Calif., says you may be protected in some cases — such as if you’re pregnant or suffering from a serious illness.

But Metz, who has fought on behalf of patients in disputes with insurance companies for 25 years, acknowledges that enforcing those protections can be challenging.

Since insurance is regulated at a state level, you need to investigate the laws in your state to find out what protections may be offered. In California, for instance, you may be able to keep your doctor or visit the same hospital if you have specified health problems or conditions.

The California Department of Managed Care tells consumers to contact their health insurance companies and request “new enrollee” continuity of care. First, though, talk to your doctor, who needs to consent to keep you as a patient. You can’t quality for continuity of care if your doctor and/or hospital doesn’t consent. Also, when you talk to your new health care provider, be prepared to discuss your medical history.

However, you may not always be able to keep your doctor. If you work for a large employer, your health plan may not be subject to your state’s insurance laws. Some large employers have self-insured plans. This means they design the health plans and bear the risks rather than pay premiums to insurance companies (although they might pay a third party, such as an insurance company, to administer the plans). Health plans that are self-insured aren’t legally required to follow state laws. Instead, they generally follow federal laws administered by the U.S. Department of Labor.

Health insurance changes: how to keep your doctor

If you don’t want to lose your health care provider, Metz suggests writing a simple, truthful letter to your employer and health plan detailing why you need to keep your doctor, and be prepared to back it up with documentation.

“Make it clear that it’s a serious issue, but don’t be hostile,” he says.

If you fail to get results, contact your state’s department of insurance to learn your rights and receive help in resolving the dispute. Some states, such as California with its Department of Managed Care, have regulatory bodies that specifically target HMOs (in addition to the department of insurance) which regulates health insurance companies. In other states, regulation of managed care is handled primarily by the state’s department of insurance. Some states, such as Connecticut and California, also have a health care or patient advocate office, which helps consumers resolve issues with health plans.

If you still can’t find satisfaction, which Metz says is unfortunately too often the case, check with health care advocacy groups such as JustHealth to see if they can provide any assistance.

Penny Gusner

Contributor

Penny is an expert on insurance procedures, rates, policies and claims. She has extensive knowledge of all major insurance lines -- auto, homeowners, life and health insurance. She has been answering consumers’ questions as an analyst for more than 15 years and has been featured in numerous major media outlets, including the Washington Post and Kiplinger’s.

Your rights when your health plan changes

HMO coverage has driven provider switches

Consumer protections vary when employer switches health insurance plans

Health insurance changes: how to keep your doctor

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