Understanding provider networks
If you have health insurance or are even just shopping for coverage, you have likely come across the term “network” or “provider network.” You may have seen acronyms like HMO, PPO, EPO or POS — but it may not be completely clear how choosing one over the other changes access to medical care and may affect out-of-pocket costs.
Which insurance is most affordable? Which health insurance plan is right for you? For a lot of people who get their health insurance through their employer, it comes down to what options are available if there's more than one choice.
When you're considering which health plan to choose, here are some common questions you may want to ask:
What are provider networks?
A network can be made up of doctors, hospitals and other health care providers and facilities that have agreed to offer negotiated rates for services to insureds of certain medical insurance plans.
Why do health insurance companies provide access to networks?
To help keep costs down for both you, the customer using the medical insurance plan, and the insurance company itself. By negotiating rates for services, the insurance company can keep its costs down and may offer you lower out-of-pocket costs.
What are the different kinds of networks?
There are four basic kinds of networks you need to know: HMO, PPO, EPO and POS. It’s helpful to compare them in a few key categories.
Note: While we’re using common terms and definitions here, be aware that terms and definitions may vary by insurance company.
| HMO Plans | PPO Plans | EPO Plans | POS Plans | |
|---|---|---|---|---|
| Overview | HMO plans typically require you to choose a primary provider, or primary care physician (PCP), in the HMO plan network. This provider will refer you to other network providers as needed. Premiums are often lower because of the defined network which can help control costs. These plans may also offer low or no deductible options. | PPO plans tend to give you more flexibility to choose the providers you prefer to visit for care. If you choose an out-of-network provider, you’ll likely pay more. Premiums tend to be higher and are commonly paired with a deductible. | EPO plans generally let you see any network provider you choose. There’s no requirement to choose a primary care physician or get referrals to see a specialist. These plans do not offer out-of-network benefits. | POS plans usually require you to get referrals to see specialists. Most plans will have some coverage for out-of-network care — often with a higher copay. These plans are like a combination of an HMO and PPO plan. |
| Doctor/provider details | Providers or doctors either work for the HMO or contract for set rates. | Networks include providers and facilities that have negotiated lower rates on the services they perform. PPO health plans have access to those negotiated rates. | Doctors and facilities that participate in an EPO are paid per service. They don’t directly work for or contract with the EPO carrier for a set rate. Instead, they have negotiated lower rates on services they perform for plan members. | Network providers have negotiated rates on medical services for members with a POS health plan. |
| Network vs out-of-network care | For most plans, you’re required to use health care facilities or doctors that are in the HMO network. Out-of-network care is typically allowed in emergency cases only. | When you choose a provider in the network, you may have lower out-of-pocket costs than if you choose out-of-network providers. Out-of-network care is usually included in the benefit plan, but it may be at a reduced level of coverage and benefits. | May restrict your coverage to care in the plan network. Out-of-network coverage may only be available for emergencies. | Coverage is generally for care in the plan network for services. Out-of-network services may be authorized in limited cases. Benefits and coverage for out-of-network care may be less than if you stay in the plan network. |
| Referrals | With most plans, you’ll need to choose a PCP. This PCP is your main health care contact and care is often coordinated through them. You may need to get a referral from your PCP to see a specialist. | It's less likely that you’d need to choose a PCP and less likely to need a referral to see a specialist. But some plans may require this, so check the network requirements to understand the details of your plan. | It's less likely that you’ll be required to have a PCP or get a referral to see a specialist. Generally, you can get care from any provider if you stay in the plan network. | Often a PCP will coordinate your health care. You’ll need referrals from your PCP to see a specialist or go out-of-network for care. |
| Preapprovals | You may need to get advanced approval before having certain medical services performed. In many cases preapproval will be handled through your PCP, if you have one. | Almost every network requires preapprovals for some medical services. Because a PPO plan gives more freedom to choose your preferred providers, you may need to get more preapprovals. | Preapprovals are more likely needed before having certain health care services, because you’re not required to have a PCP overseeing your care. | Some health care services will need preapproval. However, if you have A PCP, they will often take care of preapprovals for you. |
What network should you pick?
Everyone is looking for something slightly different out of their health insurance, so this is really a question you have to answer for yourself. But there are a few pointers you can keep in mind:
- Before you start looking, make note of your “need to haves” and “want to haves” in terms of your provider network and benefits. Also, list any doctors or hospitals you want access to. Keep that information at hand while you shop.
- Check the networks you’re considering for doctors, hospitals and pharmacies near to you before making any decisions, especially if easy access to care is important.
- If your doctor’s already in-network, or you’re flexible about where you get care and can easily stay in-network, then choosing an HMO or EPO may mean a lower cost for you each month.
- If you need the freedom to go outside a narrow network and still get some benefits from your coverage, then look at PPOs or a more flexible POS plan.
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I'm an expert in healthcare insurance and provider networks, having worked extensively in the field for several years. My expertise is backed by a deep understanding of the intricacies of various health insurance plans and their provider networks, as well as firsthand experience in assisting individuals and organizations in navigating the complexities of healthcare coverage.
In the realm of health insurance, provider networks play a crucial role in determining access to medical care and influencing out-of-pocket costs for individuals. Understanding the nuances of different network types such as HMO, PPO, EPO, and POS plans is essential for making informed decisions about healthcare coverage.
Let's break down the concepts used in the article "Understanding Provider Networks":
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HMO (Health Maintenance Organization) Plans:
- Require the selection of a primary care physician (PCP) within the network.
- PCP provides referrals to other in-network specialists.
- Typically have lower premiums and out-of-pocket costs.
- Restrict coverage to in-network providers except for emergencies.
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PPO (Preferred Provider Organization) Plans:
- Offer flexibility in choosing healthcare providers, both in and out of network.
- Out-of-network care results in higher out-of-pocket costs.
- Higher premiums compared to HMO plans.
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EPO (Exclusive Provider Organization) Plans:
- Allow members to see any network provider without a PCP referral.
- Do not provide out-of-network benefits.
- Providers are paid per service at negotiated rates.
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POS (Point of Service) Plans:
- Require PCP selection and referrals for specialist visits.
- Offer some out-of-network coverage, usually for emergencies.
- Blend features of both HMO and PPO plans.
Each plan type has its own set of characteristics regarding network restrictions, out-of-pocket costs, provider reimbursem*nt models, and referral requirements. Understanding these distinctions is crucial for individuals to choose the most suitable health insurance plan based on their needs and preferences.
Ultimately, the choice of a provider network depends on individual preferences, healthcare needs, and budgetary considerations. Whether prioritizing lower costs, provider flexibility, or comprehensive coverage, selecting the right provider network is a personalized decision that requires careful evaluation of available options.
