It’s the most wonderful time of the year! We finally get to break out our winter coats, sip hot chocolate, and spend time with friends and family for the holidays. It is also the time of the year to review your health insurance enrollment options. Maybe not the top of the list for the most wonderful time of the year, but still consistent with the season. Should you stay with your existing plan? Make a change to a new carrier?

Whether this is your first time to enroll through the marketplace, you are re enrolling through your employer, or anywhere else on the spectrum, one of the first things you should verify is you will be able to use your insurance with your preferred physician. You might hear some refer to this as being “in-network” which means that the carrier has decided that it will pay for services from that particular provider. But, this goes one step further. Your provider also has to decide if it will accept patients with that insurance coverage. It is a two-way street and many have found themselves caught in the cross traffic.

Health Insurance Card in Hand With No Physician In Sight

One of the enormous benefits of the Affordable Care Act has been the success in giving access to millions of people that did not previously have a way to afford the ACA including millions of individuals now having access to care who did not previously. But as patients have gone to find a provider that takes their carrier, they are discovering it to be a harder task than originally thought. The physician practice is either at capacity with patients are they have decided that they will not be accepting that particular insurance carrier.  Making it more confusing is how difficult it is to understand on the carrier’s website if the physicians listed are just approved as in network, or if the practice is also accepting patients.

For some, they previously were on an employer-sponsored plan and had a life change that led to enrolling in an ACA plan. Patients are seeing that their current physician is no longer taking the ACA plan. Or their specialist is covered with ACA, but they cannot find a primary care doctor to see to get the necessary referral to see their specialist. If your specialist has been with you for some time treating your chronic illness or if they have completed complex surgeries for you, it can be frightening to be forced into making the change.

But I Thought If I Had a Doctor I Liked…

Why exactly is this happening? One reason comes down to brass tax. Reimbursement rates (or what the physician gets paid from the carrier) are going down on government-sponsored plans to decrease spending. As a result, there is a growing trend to limit the number of Medicare or Medicaid patients that practice with accepting. Part of the benefit of the Affordable Care Act was to increase the reimbursement rate for Medicaid patients but if you live in a state that did not expand Medicaid, practitioners are not benefiting from increased payment rates.

The ACA plans are no exception especially considering the payout on these particular plans tend to be even lower than Medicare. As a frame of reference, for every dollar that a private plan would pay, Medicare typically pays 80 cents and an ACA plan will pay 60 cents. To add fuel to the fire, many patients with a new plan through the marketplace tend to be sicker and they take up more time from the physician. Not only are they making less money on the new patient population, but they are spending more time with them during the consult.

Many provider networks are also seeing that patients are not able to pay their patient portion because deductibles are so high. The patient will receive a full workup only to find out that they cannot afford to pay the out of pocket expense.  Or, the worse scenario is that the patient is no longer able to pay their premium. If it is an ACA plan, a grace period is given for ninety days where it appears that the patient has coverage and services will be billed as if it is an insured patient. If premiums are not eventually paid, services provided at that time are now the financial responsibility of the patient. If that individual was not in a position to afford their premium, chances are likely they will not be able to pay for the medical expenses either. As a result, the physician will be paid for that service.

If you can find a practice that takes your insurance carrier, many are just at full capacity. With the sudden increase in those that have access to care, especially for preventative services, patients are taking advantage of their new access to care. Also, our baby boomers are beginning to age into a phase of life where consistent preventative care is critical for their continued health. Therefore, they are more consistently seeing their primary care doctor. Finally, the physician shortage in the United States, especially within general practice, is only continuing to increase. As a result, we have more people needing to see general practitioners with fewer on the market.

Four Suggestions to Access the Provider You Prefer

As you are reviewing your options to make a decision on coverage, it is important that you call your physician and ask them if they will be taking your insurance next year. The marketplace information will normally be accurate on what practices are in the network, but it is impossible for it is kept up to date on the physician’s decision. The best way to find out is by calling directly.

If you are told that the physician is not accepting an ACA insurance, feel free to ask them if they are taking the same carrier if it is a non-ACA plan. If the response is yes, you most likely can find the same plan off-the-exchange.

You also can always decide to pay for your healthcare as an uninsured patient. They hospital is required by law to charge you the insurance companies negotiated rate, but if you pay cash, you’ll often get a discount. It won’t count against your deductible. You’ll need to ask up front if they take cash discounts.

Finally, ask your insurance company for options. They will usually work with you to find an in-network doctor. Keep track of the work you do as you might be able to make a case for your carrier to consider out-of-network coverage. The insurance company might examine the situation a network adequacy gap if there are no other options. Depending on the individual helping you from the carrier, you can only ask what information might help you make your case.