Doctor leaves network mid-year? First, ask your insurer about continuity of care. If you are in active treatment, pregnant or scheduled for surgery, federal law lets most ACA and job-based plans cover that doctor at in-network rates for up to 90 days. Use that time to move records, refill prescriptions and find a new doctor. Then pick a plan that includes your doctors at Open Enrollment.
- Under the No Surprises Act, continuing care patients can keep in-network terms for up to 90 days after a doctor's contract ends.
- Qualifying situations include serious and complex conditions, inpatient care, scheduled non-elective surgery, pregnancy and terminal illness.
- The protection doesn't apply if the doctor was removed for fraud or quality problems, or if you have a short-term plan.
- A doctor leaving your network is not, on its own, a qualifying life event for a mid-year plan switch.
- For 2027 coverage on HealthCare.gov, Open Enrollment runs November 1 through January 15.
Why your doctor leaves your network
In most cases, a doctor leaves your network when their contract with your insurer ends. Often, the two sides can't agree on payment rates. Other times, a medical group joins a new hospital system, or the doctor retires or moves. Insurers also redraw networks before a new plan year.
Either way, the result for you is the same. Out-of-network care usually costs more, and HMO and EPO plans may not pay for it at all. To see the gap in dollars, read how in-network and out-of-network prices compare. For the bigger picture, our guide to HMO, PPO, EPO and POS rules explains what each plan type pays outside its network.
Your continuity of care rights
Federal law gives some patients a bridge when a doctor's contract ends or isn't renewed. In fact, this protection, called continuity of care, comes from the No Surprises Act. It covers most job-based plans and individual plans, both on and off the Marketplace.
Who qualifies for continuity of care
| You may qualify if you are | What that can include |
|---|---|
| Treated for a serious and complex condition | Ongoing, specialized care for an acute or chronic illness |
| Receiving inpatient or institutional care | A hospital stay or care in a facility |
| Scheduled for non-elective surgery | Surgery plus the follow-up care after it |
| Pregnant and in treatment | Prenatal care through delivery |
| Terminally ill | Treatment for that illness |
How the 90 days work
Your plan must notify you in a timely way if you are a continuing care patient. Then you can ask to keep seeing that doctor on in-network terms. Coverage lasts until 90 days after the notice, or until you no longer need that care, whichever comes first. Meanwhile, the doctor must accept the plan's payment plus your normal cost sharing as payment in full.
These rights don't apply if the insurer removed the doctor for fraud or quality problems. They also don't cover short-term plans. Federal rules are still pending, so plans follow a good-faith reading of the law for now, and some states add their own protections.
Doctor leaves network? Take these 6 steps
Once a network change notice arrives, start with step one. Most of these calls take only a few minutes, so knock them out in one sitting.
- Confirm the change and the date
Call member services for the exact end date. Contracts sometimes get renewed at the last minute, so check again close to that date.
- Ask for continuity of care
If you are in treatment, ask how to request it. Then get the approval and the end date in writing.
- Move records and refill prescriptions
Ask the office to send your records to the new doctor. Also, request refills and referrals while you're still covered.
- Find a new in-network doctor
Search your plan's directory, then confirm by phone before you book.
- Request a network exception if needed
When no nearby in-network doctor offers the care you need, some plans approve in-network rates for an outside specialist.
- Compare the cost of staying
PPO and POS plans pay part of out-of-network care. Some offices also offer a cash price.
Tools for finding your next doctor
For step four, use our five checks that confirm a provider's status. Next, open our carrier-by-carrier search links. And if you need a new main doctor, read our tips on picking a primary care physician.
Staying with your doctor vs switching
Once any transition period ends, you face a real choice. So weigh both paths in dollars, not just in loyalty.
- Out-of-network prices on PPO and POS plans
- Often no coverage on HMO and EPO plans
- Possible bills above the plan's allowed amount
- Your normal copays and deductible apply
- Visits count toward your yearly cap
- Takes time to transfer records and build trust
If you plan to stay long term, ask the office for its self-pay price. Then compare it with what your plan would pay out of network.
Read every renewal letter your insurer sends in the fall. Network changes for the next plan year often show up there first. Also, ask your doctor's billing office directly whether they plan to stay with your plan next year.
Can you switch plans when your doctor leaves?
Usually not right away. A doctor leaving your network is not, by itself, a qualifying life event for a Special Enrollment Period. Events that can qualify include moving, losing other coverage, getting married or having a baby. You can review life events that open a mid-year enrollment window to see if one applies.
Otherwise, your next chance is Open Enrollment. For 2027 coverage on HealthCare.gov, it runs November 1 through January 15. Pick a plan by December 15 for coverage that starts January 1. State-run exchanges can set different dates, so check every enrollment date and deadline.
A licensed Vivna agent can check which plans in your ZIP code include your doctors before Open Enrollment closes, at no cost to you.
Pregnancy, surgery and ongoing treatment
When you're in the middle of care, timing matters most. So here is where to focus first, based on your situation.
Ask for continuity of care right away. Also, confirm the network status of the hospital where you plan to deliver.
Non-elective surgery and follow-up visits can qualify, and the surgeon's office can often help with the request.
Ongoing treatment can qualify, so ask your care team for a written transition plan.
Next, check the hospital, lab and imaging center tied to each doctor. Any of them can change networks too. Finally, look at your plan's yearly cap, since it limits covered in-network costs. Our guide explains how the yearly spending cap works. If your plan denies a request, you can file a formal appeal with your insurer.
How to avoid this next year
You can't stop a contract dispute. However, you can lower the odds that a doctor leaves network status in the middle of your treatment, without warning. These habits help.
- Review your plan every fall with a yearly coverage checklist
- List every doctor, hospital and prescription you want to keep
- Check each doctor against next year's network before renewing
- Weigh a broader network if you see many specialists
For a full walkthrough, use our yearly coverage review checklist. Also, PPO plans often cost more but pay something outside the network, as our side-by-side HMO and PPO comparison shows. Then compare ACA and private medical plans by network first and price second.
Doctor leaves network? Ask about continuity of care before you ask about a new plan.The rule our licensed agents repeat most
Doctor leaves network: FAQs
Will my insurer tell me if my doctor leaves the network?
If you are a continuing care patient, your plan must give you timely notice of the change and your right to transitional care. Other members may only see the change in the online directory. So check your doctor's status before each new plan year, and call member services if anything looks different.
How long can I keep seeing my doctor at in-network rates?
If you qualify for continuity of care, up to 90 days after the plan's notice. However, the period ends sooner if you no longer need that ongoing care. During that time, the doctor must accept the plan's payment plus your normal cost sharing. Ask for the approval and end date in writing.
Can my doctor still see me after a provider leaves your network?
Yes. The doctor can still treat you, but you usually pay out-of-network rates. That changes if you qualify for continuity of care or your plan grants a network exception. On an HMO or EPO, routine out-of-network care may not be covered at all, so ask for the full price first.
Does continuity of care apply to short-term plans?
No. The federal rule covers most job-based plans and individual plans on and off the Marketplace. Short-term plans are not ACA-compliant, so these protections don't apply. Short-term plans can also exclude pre-existing conditions, and they don't qualify for subsidies. Read your policy, or call your insurer, to learn what it offers.
What if my dentist leaves my dental network?
First, dental plans have separate networks and different rules. Stand-alone dental plans fall outside the No Surprises Act, so the 90-day protection may not apply. Call your dental plan and ask what transition options it offers. Then follow our steps for locating a covered dentist, or call 888-730-6031.
Vivna's licensed agents compare plans from 50+ carriers and check your doctors before you enroll. Call Monday through Friday, 9am to 6pm.
Sources
- CMS: No Surprises Act training on transitional care and provider directories
- HealthCare.gov: Open Enrollment dates and deadlines
- Know your rights when using insurance, from CMS
- HealthCare.gov: Special Enrollment Periods
- CMS: No Surprises Act implementation status
Vivna Insurance is a licensed, independent health insurance agency (NPN 19168641). We are not affiliated with HealthCare.gov or any government agency. Plan availability, networks and benefits vary by state and change over time. This guide is general information, not legal advice. Short-term plans are available only in approved states and are not ACA-compliant coverage.
Related guides
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