About Medicare
My Doctor Dropped Out of Network—What Should I Do Next?
When Can a Doctor Drop Out of Network?
Doctors and healthcare providers can leave a network plan at any time due to contract disputes, retirement, or changes in their practice. Medicare Advantage plans (Part C) and other network-based insurance plans establish agreements with providers, but these agreements are not permanent.
Your doctor may decide not to renew their contract, or the insurance company may remove them during a routine network review. Either way, these changes can impact your ability to receive in-network care. Since Medicare Advantage plans operate within a network, this could leave you paying for your visits out-of-pocket if you continue seeing your doctor.
How Much Notice Is Required Before a Network Change?
The timing of notice depends on whether the doctor or the plan initiated the change. Medicare Advantage plans must notify enrollees when a significant network change occurs. However, minor changes, like a single doctor leaving, do not always trigger a required notice period. Even though network plans can change at any time, beneficiaries should regularly check their plan’s provider directory to ensure their preferred doctors are still in-network.
Doctors, on the other hand, may or may not notify patients directly when they leave a network. Some will send letters or emails, while others may simply stop accepting your insurance at your next visit. If you receive a notice, review it carefully to see when the change takes effect.
Do I Qualify for a Special Enrollment Period (SEP) If My Doctor Leaves the Network?
A Special Enrollment Period (SEP) allows Medicare beneficiaries to change their plan outside of the standard Medicare enrollment periods due to qualifying life events. However, a doctor leaving a network is usually not enough to qualify for an SEP unless the change is considered a significant network disruption—such as a hospital or large provider group leaving.
Medicare Advantage plan enrollees typically have these key enrollment periods:
- Annual Enrollment Period (AEP) (October 15 – December 7): Switch or drop your Medicare Advantage plan.
- Medicare Advantage Open Enrollment Period (January 1 – March 31): Change your Medicare Advantage plan or return to Original Medicare.
- Special Enrollment Periods (SEPs): Triggered by life events like moving, losing coverage, or major network changes.
Unless a large-scale provider change occurs, you likely won’t qualify for an SEP simply because your doctor left the network. This means you may need to wait until AEP or another eligible period to switch plans.
What Can I Do If My Doctor Drops Out of Network?
If your doctor is out of network, you still have options:
- Check if the doctor offers out-of-network coverage. Some Medicare Advantage plans provide coverage for out-of-network services at a higher cost.
- Find a new in-network doctor. Your plan’s provider directory will list in-network physicians, or you can call customer service for recommendations.
- Pay out of pocket. If you strongly prefer your current doctor, you may continue seeing them and pay full costs.
- Consider switching plans. If your doctor accepts another Medicare Advantage plan, you can switch during AEP or another eligible period.
Understanding these options can help you minimize disruption in your healthcare. Always verify costs before continuing care with an out-of-network provider.
Medicare Advantage vs. Medigap: Why Network Matters
Unlike Medicare Advantage plans, Medigap (Medicare Supplement) plans do not have networks. This means that with a Medigap plan, you can see any doctor who accepts Medicare, regardless of network restrictions.
Medigap plans help cover costs like copayments and deductibles under Original Medicare, but they do not include prescription drug coverage. In contrast, Medicare Advantage plans often include prescription drug coverage but require you to stay within the plan’s network for most services.
If provider stability is a concern, switching to Original Medicare with a Medigap plan may be worth considering. However, Medigap plans require medical underwriting in most cases, so qualifying may depend on your health unless you have a Guaranteed Issue (GI) Right, are new to Medicare Part B, or live in a state with expanded GI Rights.
Navigating Network Changes in Medicare Advantage Plans
Medicare Advantage plans operate within networks, so doctors can leave at any time. Unless a significant network change occurs, an individual doctor leaving will not trigger an SEP, meaning you may need to wait until the next enrollment period to switch plans.
If your doctor is out of network, explore in-network alternatives, check out-of-network coverage costs, or consider plan changes. Consulting a licensed insurance agent can help you understand your options and choose a plan that fits your healthcare needs.
Need Help Navigating Your Medicare Plan?
If your doctor is out of network and you’re unsure about your options, AMAC’s team of Medicare Advisors can provide personalized guidance by helping you:
✅ Find in-network doctors covered by your current plan
✅ Explore whether switching plans is an option for you
✅ Understand Medicare Advantage vs. Medigap coverage
✅ Compare plans to ensure you’re getting the best benefits
Don’t wait until it’s too late- contact us today to discuss your healthcare needs – Call 855-611-4856!
