My Medicare Advantage plan listed my doctor, but now they say he's out of network. How is that even allowed?
Answered by 26 licensed agents
That can be frustrating! Medicare Advantage plans typically have contracts with specific networks of doctors, hospitals, and other healthcare providers. However, sometimes these contracts change throughout the year. Even if your doctor was in-network when you enrolled in your plan, they might have been removed from the network later due to changes in the insurance company’s agreements or policies.
Unfortunately, this can happen, but you do have some options.
It is the doctor's choice to go out of network. There are various reasons for it but unfortunately, it seems to always come at the time you really need their services and you are no longer covered as they are out of network.
Doctors can leave a network at any time of year. We prefer they would do so at the beginning of the year and notify clients during the Annual Enrollment Period but there is no rule saying they have to do so. Also, sometimes doctors are not leaving a network due to choice. It could be they belong to a large organization and that organization did not recontract with a carrier. It can also be a doctor being removed due to poor quality ratings. It can be very frustrating for the clients affected by network changes.
Although Medicare Advantage plans have contractual agreements with healthcare providers, there a certain instances of which there can be a breakdown of negotiations between the parties thus giving doctors the right to refusal to accept the insurance carriers terms. Should this happen, the doctors and healthcare systems will or should notify the affected patients that their current plan is considered out-of-network or not being accepted at all.
Ahhh… you’ve run into the thing I caution my prospective clients about all the time! A doctor does not have to accept or stay accepting an MA plan. Remember these are privately held companies, and what services they provide and what methods of payment are NEVER equal to having Original Medicare, which you forfeited when you accepted the MA plan.
See, Doctors make more and are paid faster with Original Medicare - within 30 days, because they are government and bills must be paid within those 30 days. However, private company insurance always pays a Doctor(or other Medical Professional) less, and can wait 90-120 days to pay! Sometimes longer! So why would a good, qualified, top tier Doctor continue to accept an MA PLAN? Sooner or later the cream rises to the top!
My suggestion if you like that Doctor is to go back to Original Medicare and add a good Supplemental plan. It’s the best you can do! If you’re in Florida or PA, I can help you!
Your doctor can choose the insurances they take. If the doctor opts out of taking an insurance, They will now by default become out of network with that insurance company as they do not have to bill them. It is always good to make sure that you are up to date with the insurances your doctor's office takes as they can change.
Unfortunately, doctor that works changed throughout the year. It’s not very often a change, but it does happen occasionally. You will just have to find another doctor that you were happy with that is in the network. Most plans these days are PPO’s which means you can go out than never at a higher co-pay. If you have one of those plans, you still may be able to see your doctor if you wish to pay the higher co-pay.
Doctors can move in or out of network often depending upon if they change groups or move out of the area. Doctors and facilities moving out of network is one of the many reasons I recommend an Advantage PPO over an HMO if one is available.
It is possible for a doctor to leave a Medicare Advantage plan's network, even if they were previously listed as in-network. This can happen because Medicare Advantage plans contract with providers, and these contracts can be terminated or not renewed, leading to a provider dropping out of the network. Here's a more detailed explanation:
Contracts with Providers:
Medicare Advantage plans establish agreements with healthcare providers, but these agreements are not necessarily permanent.
Provider Decisions:
Doctors or other providers can decide not to renew their contracts with a specific plan, or the plan may choose to remove them during a network review.
Changes in Network:
Provider networks can change at any time during the year, and you may be notified by your plan if significant changes occur.
Impact on Your Care:
If a provider leaves the network, you may need to find a new in-network doctor to continue receiving care covered by your plan
The question is, where was that listing? If it was in a printed book that your plan sent you, that is notoriously inaccurate due to when it was printed! The best way to look up a Dr is on the plan's provider website, and then call the Dr to double check. But it is possible that during the year, a Dr can go off network. That was either done by the Dr or the plan, for reasons unknown to you and it is allowed.
Doctors are allowed to decide what insurance carriers they will accept. Depending on the plan you have the copays may be the same or possibly higher. Just as your doctor has the choice on what insurance he will accept, you can always find a new doctor who accepts the plan you bought.
Provider contracts can change throughout the year. This is why a provider may have been in network when you enrolled into the plan and then out of network after.
I see this problem a lot because AEP is 10/15-12-07 and starts 1/1 of the next year. But Doctors leave or go to a network also at the beginning of the new year. Most enrollment hubs update weekly or monthly for providers . But most transitions come at the new year. Having a conversation with your Doctor or at least Office Mgr might be of value . A reason for enrolling in a PPO is you can in and out of network also using Original Medicare with a supplement will immediately solve this problem.
Medicare Advantage plans have the flexibility to modify their network of healthcare providers throughout the plan year. This means that your plan may add or remove doctors, hospitals, or other healthcare professionals at any time. However, regulations require that your Medicare Advantage plan provide you with a minimum of 30 days' written notice before any network changes take effect.
If your provider is removed from the network, you may need to select a new in-network provider to continue receiving covered care at the plan’s negotiated rates. In cases where a provider is terminated without cause, plans may offer temporary coverage to allow members time to transition to a new provider.
The in Network providers and hospitals renegotiate contracts with carriers overseen by CMS Centers of Medicare & Medicaid Services each year and sometimes deadlines and negotiations are not met especially in some of the small rural areas where the networks are small. You will need to contact your carrier and request a new primary care physician. Also, you can check other carriers to see if your doctor is in their networks and switch during the Annual enrollment period October 15 - December 7th.
Doctor's have to, annually, engage with the various Medicare Advantage plans. I'd suggest double-checking with your doctor to see if they are connected with your MAPD provider. If they are, you're good to go! If they are not, I'd reach out to your MA plan and question the initial sign up communication. If your MA provider used to be in network and now is not...they have created a "special enrollment period" and you should be able to try and move to a new MA plan that your doctor is enrolled.
Medicare Advantage plans, negotiate contracts with providers. These contracts can change even on an annual basis. If the contract is not renewed, the physician can be considered out of network. That’s why it’s important to have a plan like a PPO that would participate without a network doctors.
Doctors are able to drop out of a Network in the middle of the year. It is always a good idea to review your Medicare Advantage Plan every year during the Annual Election Period from October 15th - December 7th.
Doctor’s networks unfortunately change all the time. If your plan isn’t currently working , give me a call 682-412-7537 and I am happy to see if you may qualify for a special enrollment period .
This can happen because provider network in Medicare Advantage plans can change at any time. Doctors may leave the plan, or the plan may update it's list without noyice. just because a doctor was listed when you enrolled doesn't guarantee they'll stay in-network the entire year. I always recommend confirming network status directly with the provider and the plan itself before making appointments. As an agent, I help my clients avoid these surprises by doing that verification ahead of time.
The 2025 Part D changes are likely to help with the specialty medication. Primarily, the Medicare Prescription Payment Plan --- which is a voluntary payment option for managing out-of-pocket prescription drug costs, allowing a client to spread payments across the year instead of paying the pharmacy directly.
Secondly, beneficiaries no longer have to deal with the donut hole / coverage gap.
Advantage plans are not governed by the Department of Health and Human Services, specifically the Centers for Medicare and Medicaid Services (CMS). Insurance companies control what advantage plans do and do not cover and they contract with providers. These contracts are not permanent and can change from year to year. Doctors and providers can choose to leave a network if they so choose. That's why I always recommend traditional Medicare and a Medigap policy.
Unfortunately, Medicare Advantage plans work with networks that can change at any time. Just because a doctor was listed as in-network when you enrolled doesn’t guarantee they’ll stay that way for the entire year.
Doctors can leave the network, or the plan might update their list—sometimes without much notice. That’s why it’s so important to review your plan each year.
If this causes a real issue with your care, there may be options like requesting continuity of care or considering a plan change during an enrollment period.
