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What You Should Know About Provider Networks

What You Should Know About Provider Networks

What’s a provider network?
A provider network is a list of the doctors, other health care providers, and hospitals that a plan has contracted with to provide medical care to the plan’s members. These providers are called “network providers” or “in-network providers.” A provider that hasn’t contracted with the plan is called an “out-of-network provider.”
How can I check to see if my doctor is in a plan’s network before I buy a plan through the Marketplace?
First, make a list of all the providers you use. Remember that both health care professionals like doctors, psychologists, or physical therapists, and health care facilities, like hospitals, urgent care clinics, or pharmacies are considered providers.

When you compare plans offered through the Marketplace on Healthcare.gov, you can sort plans by plan name. You’ll see a link to a list of providers in each plans network where you can search to see if your providers are in-network or out-of-network. Insurance companies may have different networks for different plans, so make sure that you’re searching the provider network of the
specific plan you think you may want. If you want coverage for your dependents, check a plan’s
provider directory for their providers as well. You also can call the health insurance company’s
customer service phone number to check if your providers are in the plan’s network. If you travel
a lot, check to see if the plan’s network has providers where you might need care.
How do different types of plans use provider networks?
Depending on the type of plan you buy, your care may be covered only when you see a network provider. You may have to pay more, and/or get a referral if you choose to get care from a provider who is not in your plan’s network. Types of plans include:
• Preferred Provider Organizations (PPOs): PPOs give you the choice of getting care from in-network or out-of-network providers. You pay less if you use providers that belong to the plan’s network. You’ll pay more if you use doctors, providers, and hospitals outside of the network, and you may have higher out-of-pocket costs for services you receive outside the network. If you have a PPO plan, you can visit any doctor without getting a referral.
• Point-of-Service (POS) Plans: POS plans let you get medical care from both in-network and out-of-network providers. If you have a POS plan, you can visit any in-network provider without a referral, but you’ll need a referral to visit an out-of-network provider You may pay higher out-of-pocket costs if you use an out-of-network provider.

  • Health Maintenance Organizations (HMOs): HMOs usually limit coverage to care from providers who work for or contract with the HMO. An HMO generally won’t cover or has limited coverage for out-of-network care except in an emergency. If you use a doctor or facility that isn’t in the HMO’s network, you may have to pay the full cost of the services provided. HMO members usually have a primary care doctor and must get referrals to see specialists.

• Exclusive Provider Organizations (EPOs): EPOs generally limit coverage to care from providers in the EPO’s network (except in an emergency).Health plans generally can’t require higher copayments or coinsurance if you get emergency care from an out-of-network hospital, no matter what type of plan you have. However, providers may bill you for some additional costs.
Why do some plans cover benefits and services from network providers but not out-of-network providers?
When a provider is a network provider for a plan, it means that the provider has agreed to provide benefits or services to the plan’s members at prices that the provider and the plan agreed on. The provider generally will provide a covered benefit at a lower cost to the plan and the plan’s members than if the provider provided the same benefit to someone without insurance, or someone with insurance through a plan in which the provider is an out-of-network provider.

All insurance plans sold in the Marketplace are required to have provider networks with enough types of providers to ensure that their plan members can access plan services without unreasonable delay. If you use an out-of-network provider, you may have to pay the full cost of the benefits and services you receive from that provider, except for emergency services. If you get emergency
services from an out-of-network provider, those services will be covered by a Marketplace plan as if you used an in-network provider. However, providers may bill you for some additional costs associated with the emergency services you receive.

How can I tell the different types of plans when I’m shopping in the Marketplace?

When comparing plans on HealthCare.gov, the type of plan is listed immediately below the name of the plan – look for the initials PPO, POS, HMO, or EPO. The type of plan is also listed on each plan’s “Summary of Benefits and Coverage,” which you can find on any page view of the plan. If you have a question about whether a plan is a PPO, POS, HMO, or EPO, call the health insurance company. You also can call the Marketplace Call Center at 1-800-318-2596 to ask about the coverage offered and your benefits and protections under the Affordable Care Act. TTY users should call 1-855-889-4325. You can also find in-person assistance in your area by clicking on the “Find Local Help” link on HealthCare.gov.

What can I do if I’ve already enrolled in a Marketplace plan and my doctor isn’t in my plan’s network?

If you enroll in a Marketplace plan, you can switch to another plan until the date your coverage is effective. After your coverage effective date, you won’t be able to change your plan until the next Open Enrollment Period, unless you have certain life events that give you a Special Enrollment Period.

If you decide to switch plans, ask your doctor which insurance companies’ provider networks he or she is in. When you compare plans on HealthCare.gov, you can sort plans by plan name. You’ll see a link to a list of providers in each plans network where you can search to see if a doctor is in your network or out of your network.

Call the Marketplace Call Center at 1-800-318-2596 if you need help applying for coverage through the Marketplace and enrolling in the Marketplace plan you want. TTY users should call 1-855-889-4325. Find out when your new coverage will start before you cancel your current plan so you don’t have a gap in coverage.

If you enroll in a Marketplace plan and you’re eligible for a premium tax credit, you can use your tax credit right away to lower your plan premium. You can only apply the premium tax credit toward plans sold through the Marketplace.

For More Information Visit: http://marketplace.cms.gov/getofficialresources/publications-and-articles/what-you-should-know-provider-networks.pdf