Provider Networks | In-out of network

Provider Networks - The most important thing

PPO HMO EPO Accountable care organization network out of networkHealth insurance is extremely important and it's very complicated, expensive and has a lot of rules to follow. One of the most important things to understand when considering one policy over another is who is in the doctor and hospital network. Each insurance company will have several networks to choose from so you need to look specifically at the policy you are considering to see what network is being offered with that specific plan. This is often called a PPO or HMO network and it can really hurt you if you don't know exactly what you are signing up for. 

In vs. Out of Network

When you compare policies and benefits you will see most talk about "in network benefits. That is referring to the doctors, clinics, hospitals and other providers you can use with your health plan. Each of them has agreed to specific pricing and rules of engagement for your treatment. When you visit a "non-participating provider they are able to charge you any price they want and the insurance company cannot do anything about it. So, in order to encourage you to stay "in network they penalize you substantially for not following the rules. Your deductible and out of pocket are usually doubled and more importantly, you are responsible for paying any charges that are not agreed upon by your insurance company.

What should you do? Before signing up for an insurance policy, you should think about your preferred doctors and the doctors and hospitals you want to be able to use if you become sick or hurt. You won't be able to change when you need the insurance so you must make these decisions upfront. What you will find is the plans with the biggest networks giving you a lot of options and choices will be more expensive than those with small or limited networks.

You are able to make changes to your policy once a year at open enrollment, this will generally take place at the one year anniversary of the policy.  If you don't make the change during this time, you will be locked in for another 12 months unless you have a credible event like marriage or the birth of a child.
 

Narrow or Skinny Networks

This is a new term to describe new networks the insurance companies are building toout of network PPO skinny network ACO HCA Vanderbilt keep prices competitive on the Marketplaces. The deal is, with a network that offers fewer doctors and hosptials they can work out better pricing with those providers because the will steer more patients to them. When you look and compare the benefits for two identical plans with very different pricing, the difference will most likely be the less expensive plan has a much smaller listing of "in network doctors and hospitals. If you are ok with the providers in that network it may be a good choice for you but should you want to use a different hospital or provider, you will not be able to without paying a MUCH higher cost for services if it is covered at all. Something else you will find is the medical plans offered "outside" of the Marketplace will tend to have more options and bigger networks. Of course,  you don't get subsidies outside of the marketplace. 

Emergencies “ Most policies will allow you to go to the nearest hospital or facility in an emergency and will treat the expense as being "in network. If you have a choice, you should still try to use a network provider but this is the one case where you have some flexibility. 

Links to carrier network searches (find a doctor or hospital)

BlueCross and Blue Shield of Tennessee

Aetna DocFind

Humana

United HealthCare

Cigna

 

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What is a PPO or HMO network?

In-Network & Out of Network You need to understand the difference