As part of our Robert Wood Johnson Foundation-funded Navigator Technical Assistance project, we’ve worked with navigators and assisters to answer the more complex questions they get from consumers trying to understand their coverage options. Now that open enrollment is over, Navigators are starting to hear from consumers they helped enroll and who are returning with questions about their coverage. One such question from Georgia illustrates one of the challenges consumers may face – a network that changes mid-year.

In this case, the individual selected a plan because it covered local doctors and a hospital at a cost he could afford. However, that changed once he was enrolled and the open enrollment period had closed. When he tried to use his coverage, he learned the provider he wanted to use was no longer in the network. In fact, he said, the community hospital that acquired all the medical practices in the county withdrew from the network.  Now he has a plan that he cannot use without traveling a long distance to see a provider.  Can he change plans to one that includes providers in his area, he asked the Navigator? Unfortunately, the answer is no, but he may have some options to make the most of the coverage he has.

CCIIO released guidance in February allowing for a limited opportunity to change plans in order to move to a plan with a more inclusive network, but that opportunity was only available during Open Enrollment.  Provider networks can change over the course of the plan year for any reason, including because a provider chooses to leave the network, as happened with the Georgia consumer’s plan. However, consumers are locked into the plan for the full year, unless they qualify for a special enrollment period to change plans.

Consumers in this situation have a few options:

–          They can file an appeal with the insurer to see if they can obtain care from out-of-network providers at in-network cost-sharing. More information on how to appeal a health plan decision can be found in our Navigator Resource Guide (FAQ # 262).

–          Depending on the plan rules, consumers may be able to obtain care from other, local providers but with higher cost sharing. If it’s an HMO without any out-of-network coverage, that won’t be an option. But the Summary of Benefits and Coverage will include information on whether enrollees can obtain coverage out-of-network and what they may pay for those services. In addition to higher cost-sharing for out-of-network care, consumers may also be subject to balance billing (the difference between what the plan will pay for a covered service and what the provider charges). Plans are not required to count costs for out-of-network care or any balance billed charges toward the out-of-pocket limit. The Summary of Benefits and Coverage will provide details on that, too.

–          Finally, some states have “continuity of care” laws that require insurers to cover services obtained from a provider that is no longer in-network for a period of time; however, these laws vary and can offer only temporary relief. In the case of Georgia, consumers receiving care for a chronic or terminal illness, or who are hospitalized, can continue to see their provider for 60 days after they are no longer participating in the plan’s network. Similarly, HHS released guidance in December strongly encouraging marketplace plans to allow consumers to temporarily get out-of-network care at in-network cost sharing if the provider directory was out-of-date when the consumer enrolled in the plan.

It’s also worth noting that consumers can and should report such a change in network to their state department of insurance, which is charged with enforcing network adequacy standards for fully insured plans.  Consumers can also contact a plan’s member services department to see if there is anything they can do to help address the hospital dropping out of the network. A formal appeal may not be necessary for the consumer to continue to see their providers at in-network cost-sharing.