How to check if an allergist takes your insurance

CMS describes a provider network as the doctors, other health care providers and hospitals that a plan has contracted with to provide care to its members.² HealthCare.gov says most health plans give the best deal on services from these in-network providers, and that visiting one usually means lower out-of-pocket costs.¹

Why the insurer’s name isn’t enough

CMS says insurance companies may have different networks for different plans.² Its guide to provider networks suggests searching the provider network of each specific plan being compared, and calling the insurance company’s customer service number to confirm that a provider is in the plan’s network.²

The guide also says that if a plan ends its contract with a provider someone is getting treatment from, that person may qualify as a continuing care patient, and it suggests contacting the plan to find out.²

Checking a plan’s network

HealthCare.gov, writing about Marketplace plans, lists several ways to check.¹

• The plan’s provider directory. HealthCare.gov suggests visiting the health plan’s website and checking its provider directory, the list of doctors, hospitals and other providers the plan contracts with. It says the directory is also available from the plan, or through a link in the plan description in a Marketplace account.¹
• The insurer. It suggests calling the insurer to ask about specific providers, at the number on the insurance card or the insurer’s website.¹
• The doctor’s office. It says staff at the doctor’s office can say whether they accept a plan.¹
• The Marketplace Call Center. It says a representative at 1-800-318-2596 (TTY 1-855-889-4325) can help find the insurer’s number.¹

If a plan doesn’t cover a visit, HealthCare.gov says there is a right to appeal the decision and have it reviewed by an independent third party.¹

Plan types and specialists

CMS lists four plan types and how each one uses its network.²

Plan type	What CMS says about the network
HMO, health maintenance organization	Usually limited to care from doctors who work for or contract with the HMO; out-of-network care isn’t covered except in an emergency
PPO, preferred provider organization	Lower costs with the plan’s network; for an additional cost, providers outside the network can be used without a referral
EPO, exclusive provider organization	Covered only for doctors, specialists or hospitals in the plan’s network, except in an emergency
POS, point of service	Lower costs with the plan’s network; referrals from a primary care doctor are required to go to specialists

Each row restates CMS’s guide.² CMS says the plan type is listed immediately below the plan’s name on HealthCare.gov and on each plan’s Summary of Benefits and Coverage.²

Medicare and Medicaid

Medicare.gov says Original Medicare covers care from any doctor or hospital that takes Medicare, anywhere in the US, and that in most cases no referral is needed to see a specialist.⁵ In a Medicare Advantage plan, it says, people may need to use doctors and other providers in the plan’s network and service area for non-emergency care, and may need a referral to see a specialist.⁵

Medicare.gov describes three kinds of providers in Original Medicare: those who accept assignment, those who don’t, and those who opt out of Medicare.⁴ It says a provider who accepts assignment takes the Medicare-approved amount as full payment for covered services, and that this is how people can get the lowest cost.⁴ A provider who doesn’t accept assignment can charge more than the approved amount, it says, though in many cases no more than 15% above it, a limit called the limiting charge.⁴ If a provider has opted out, Medicare.gov says, Medicare won’t pay for their services except in emergencies.⁴ It says most doctors, providers and suppliers accept assignment but advises always checking, and points to its Care Compare tool to find out.⁴

HHS says Medicaid varies by state and each state Medicaid agency maintains its own list of professionals that accept Medicaid; it suggests contacting the health plan or the state’s Medicaid agency for help.⁶

If a plan’s directory was wrong

CMS says the No Surprises Act requires plans to verify and update their provider directory information at least every 90 days, and to answer questions about whether a provider is in network within one business day.³ If someone gets care from an out-of-network provider because the directory information was wrong, CMS says they can’t be charged more than the in-network cost-sharing, and the plan must count those payments toward the in-network deductible and out-of-pocket maximum.³ It says a person who paid more than the in-network cost-sharing in that case is entitled to a refund of the difference, with interest, from the provider.³

CMS says these protections apply to employer plans, whether self-funded or fully insured, individual and group plans sold on or off the Marketplaces, state, local and other non-federal government plans, church plans, the Federal Employees Health Benefits program and fully insured student plans.³ They don’t apply to Medicare (including Medicare Advantage), Medicaid (including managed care), CHIP, the Indian Health Service, VA health care or TRICARE, CMS says, or to short-term plans, health care sharing ministries, retiree-only plans and some limited policies, such as stand-alone dental or vision plans.³ CMS also notes that regulations for the directory rules have not been issued yet, and that plans are expected to follow them in good faith in the meantime.³ Its No Surprises Help Desk is at 1-800-985-3059.³

Where AllergyNest fits

Our allergist directory lists doctors from federal records, which don’t say which private plans a doctor is in. The label for allergists who accept Medicare assignment comes from CMS’s Doctors and Clinicians file, which marks a clinician as accepting the Medicare-approved amount as payment in full, or as one who may accept Medicare assignment.⁷ The label is only about Original Medicare’s approved amount; it doesn’t say whether a doctor is in any Medicare Advantage plan’s network.

On listings a practice has claimed, the practice can pick the insurers and programs it says it takes, such as Aetna or Medicare, shown under “From the practice”. We don’t check those entries, and they name insurers and programs, not plans. HealthCare.gov suggests checking with the plan and the doctor’s office.¹