I switched insurance mid-treatment. Can I keep my doctor or therapist?
Ask for a transition-of-care (continuity-of-care) exception, which is different from a network gap exception: it covers an active course of treatment that would be harmed by switching, for a set period, at in-network cost sharing. Many states require it for insured plans, and self-funded plans usually have their own transition policy in the plan document.
What to do, in order
- Step 1
Name the right exception
A gap exception is for when no in-network provider can provide the service at all; plans answer that with "we have in-network providers". Transition of care is about your active treatment. Ask for the plan's transition-of-care policy and form by that name.
- Step 2
Check the plan type
If the plan is fully insured, your state's continuity-of-care law sets the period (often 90 days, longer for pregnancy or terminal illness). If it is self-funded, the plan's own policy governs; ask HR or the insurer for it in writing.
- Step 3
Provider letter
Diagnosis, that treatment is active with a plan and expected duration, and why disruption now is a clinical risk. Ask the provider whether they would sign a single case agreement at the in-network rate for a defined number of visits; plans grant those more readily because the cost is bounded.
- Step 4
Appeal a refusal in writing
Ask for the written denial with the specific reason and provision, and appeal within the deadline. Continuity refusals are pre-service claims and get the shorter decision timeframes.
The deadline that applies
Transition-of-care requests are usually due within 30 to 90 days of the new coverage starting; ask the plan for its window. A denial is a pre-service adverse determination: ERISA plans must decide the appeal within 30 days (29 CFR 2560.503-1), and you have at least 180 days to file it. The letter controls.
Calculate your date →Documents to gather
- The plan's transition-of-care policy and form
- The provider's letter on active treatment and risk of disruption
- The treatment plan and expected duration
- The written denial, if any
Go deeper
Related questions
Does the No Surprises Act help here?
Its continuity-of-care rule applies when the provider leaves the network, not when you change plans. For a plan change, use the plan's transition policy and state law.
How long does a transition period last?
Commonly 90 days; pregnancy, terminal illness and scheduled surgery often carry longer periods under state rules.
What if the provider will not join the network?
A single case agreement covers this episode only and does not require the provider to join. Ask the plan for it.
Sources
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