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What to do when your prosthetist leaves your health plan

Posted by Bryan Potok on

You're among the many who get along well with their current prosthetist, whether they have been with you since the beginning of your journey as an amputee or they are relatively new. They are always there for you, helping you to live well and adjust to your new amputee lifestyle. They know you, and they anticipate your needs just as a friend would. They listen emphatically and communicate in a way that conveys an understanding of your unique health care needs.

What do you do when your prosthetist is no longer covered by insurance plan.

Finding a prosthetist with whom you can genuinely connect is a rarity in the medical world. In fact, numerous studies have found that establishing an emotional connection with your prosthetist is essential to your well-being. It is one of the most effective elements needed in a patient’s journey to recovery. And now that you have found this magical medical connection, it is understandably disappointing when you find out that your prosthetist is leaving your health plan.

Once your prosthetist leaves your healthcare network, your health insurance will no longer cover your visits to your prosthetist either in full or partial, depending on your coverage. And paying for these visits out-of-pocket may prove to be too steep for you. If you are covered by an employer’s or spouse’s health plan, you might find that it isn’t easy to switch to another health network that includes your prosthetist.

In cases such as this, you can consider three options:

1) Switch to a health network that covers your prosthetist

2) Consult your prosthetist’s office about a cash price or pay package that will allow you to continue seeing your prosthetist outside of your current health plan

3) Find a new prosthetist that is covered by your current health insurance 

Switch health plans

Switching health plans takes careful consideration and planning. So, if you’re set on following your prosthetist and changing to a health plan that covers them, then start planning as soon as your prosthetist tells you about their move. If possible, start planning well before the next open enrollment.

To help you plan your move, here are a few things that you need to factor in:

Open enrollment

Take note when the next open enrollment is scheduled. Open enrollment is that time of the year when people can sign up for individual and family coverage. However, you have to act swiftly; missing the deadline means waiting another year to buy health insurance. If you rely on your corporation’s health plan, like the majority of the population, you may ask your human resources department about the company’s open enrollment period, which usually takes place in fall.

Special enrollment period

If you missed open enrollment, check if your circumstances qualify you for a special enrollment period. You qualify for it if you have undergone the following life events: getting married, having a baby, adopting a child, moving, or losing your health insurance. You are usually given 60 days after the life event to enroll in a new health plan.

If you have set your heart on looking for a new health insurance provider, you can check your options in the private marketplace by contacting a broker or inquiring and working directly with the health insurance companies. For a comprehensive list of health insurance providers, you can check government-run marketplaces, such as HealthCare.gov.

For people with limited incomes, healthcare is available for free or less the original price through Medicaid and the Children’s Health Insurance Program. Meanwhile, adults over 65 and some individuals with disabilities qualify for coverage under Medicare.

If your health plan is under Medicare, you may want to look into 'Medicare Part B' which covers most of the needs of amputees:

  • Orthotics
      • You’ll also find various suppliers that are also enrolled in Medicare.
  • Artificial limbs and eyes
  • Arm, leg, back, and neck braces
  • Orthopedic shoes
      • These are covered by Medicare if it is a necessary part of a leg brace.
  • Therapeutic shoes or inserts
      • These are typically required for people who have severe diabetic foot disease.

Meanwhile, senior citizens who are covered by Medical Advantage health plans have the option to leave their plans if their doctors do.

But no matter what health plan you end up choosing, remember that there are at least six essential elements that you have to consider:

  • The healthcare provider network
      • Check their list of doctors and hospitals, and determine for yourself if everything you need at least for the entire year is covered by the system.
  • Included prescription medications
  • Premium
      • This refers to the cost of insurance even if you never use it. Can your monthly budget comfortably cover the monthly premium?
  • Deductibles
      • This refers to the amount you must spend before coverage kicks in.
  • Copayments
      • This refers to the fixed amount paid when you seek care.
  • Coinsurance
      • This refers to the percentage you owe on the total cost of a service.

If your answers to all six elements are favorable to a particular health insurance provider, you may have just found your match.

Negotiate a payment plan

If switching to another health plan is not possible, another option that you can explore is negotiating a payment plan with your prosthetist that allows you to continue seeing them without the high cost. A temporary solution for this is continuity of care, which ensures that a patient continues to receive quality and cost-effective medical care. But before you can make use continuity of care as a solution, you may want to check what protections your state has in place. 

In some insurance plans, continuity of care is available without being required by law. These cases cover patients with severe chronic conditions or terminal illness that require continuous health care for at least up to 12 months—enough time for a patient to make a safe switch.

If, however, you are not qualified for continuity of care, check if it would be affordable both in the short and long-term to pay out-of-pocket to continue seeing your prosthetist. Inquire also at your prosthetist’s office about the possibility of negotiating a lower cash price per consultation. It isn’t uncommon to find that some medical offices can give you a good deal because they don’t have to bill your insurance, which reduces administrative costs and removes the hassle that processing claims usually entails.

But as your out-of-pocket costs add up, you may realize that a cash arrangement may not fit within the budget. It is at this moment that you have to decide whether your current prosthetist is worth the expense based on the numbers they give you.

Find a new prosthetist.

If you have found that the first two options are unsustainable, it may be time to look into your healthcare network for a new prosthetist. Narrow down the choices to include only those that are in your area. Then consult your current prosthetist for their referral. This way, you have an idea of the quality of care you can get from your prospective new prosthetist.

Asking your current prosthetist for a referral also has another benefit. As you may have noticed, different healthcare providers usually adhere to various methods and philosophies of care. If you consult your current prosthetist, they are most likely going to refer you to someone with similar healthcare values, such as preferring regular follow-ups over the phone or advocating for lifestyle changes instead of increasing medication. So, if there is something specific you like about how your prosthetist handles things, make sure to mention this when asking for a referral. 

Prepare for next year

Now that you know how much planning is involved in keeping your current prosthetist, you will want to plan accordingly to ensure that you still get to see your current prosthetist next year. Even before insurance enrollment season comes around, inquire at your doctor’s office to verify if the insurance options you are considering are accepted before you pick one. You can also ask your prosthetist a few months before open enrollment comes around if they have plans to switch to a different health plan. 

If you are switching to a different health plan, aim to keep stress levels low during the one- or two-week enrollment period by focusing on two essential elements when weighing your plan options: cost and network.

Consider the value of the plan. If keeping your current prosthetist will double or triple your monthly premiums, will it be worth it? Furthermore, understand the network of doctors and hospitals that are included in your prospective health plan. Figure out if the health network is capable of meeting your needs. So, if you ever get stuck again, at least you’ll have a variety of new prosthetists from which you can choose.

And, most importantly, assess your health needs for next year. If you anticipate needing a lot of medical care, you may want to consider a health plan with lower out-of-pocket costs and higher premiums. If, however, you don’t anticipate requiring a lot of medical services, a lower-cost plan with less coverage may be just right for you. 


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