Special Enrollment – MD no longer participating?

Two of my regular doctors were listed in the Aetna provider directory as “Plan Participants” when I was shopping coverage last December.

***How come you didn’t do your shopping  on this website?

After my second visit this year, i learned doctor A was a participant with other Aetna plans but not mine. Doctor B was disenrolled as a Plan participant in February. I was not informed by the doctors billing office nor Aetna that the doctor was removed from my plan as a participating provider.

***That could well be a violation.  You are supposed to get 30 days notice.  Click here for more details on Q1 website the rules and when CMS might allow a special enrollment period.

What would have been $20 copay visits turned into $100+ non covered bills.

***That is a big issue and there are tons of new laws and rules in the under 65 market with Obama Care narrow lists.  Check those pages for possible relevant information:


I filed an appeal today because I now have several unpaid bills rolling in from these providers that I confirmed were plan participants when I chose my plan.

This may fall under breach of contract by Aetna.

***Have you read their evidence of coverage on that topic?  The Q1 website?

But my choice is to wait and see how the grievience goes.

***How about sending us a copy of the grievance?  Did you read the Q1 website so you know how to word your grievance?

If I am allowed to disenroll I would end up on Regular Medicare

***Q1 website says you can go into another Medicare Advantage plan.  We offer Blue Cross, Shield & UHP – AARP.

and have to choose a drug plan. I could also just stop paying the premium and be cancelled.

***I don’t think that not paying premiums is an option.  Let me check.  For one, if you were simply cancelled, you wouldn’t even have original Medicare.  Most Medicare Advantage plans are no premium, if you are paying premium it might only be for dental or vision?


***I’ll check.

I may need to switch back to Anthem. The Mediblue Access PPO shows my primary doctors as participating in the plan.

But looks like I will need a Letter of cancellation from Aetna first?

***Right, since it’s not open enrollment, which starts 10.15.2016 for a 1.1.2017 effective date  and you don’t seem to have any other reason for special enrollment.

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