When you are shopping through health insurance polices, you will likely come across the types of networks the policies provide. Many individuals don’t know what the networks actually are, what they do, or what implications they may have on their health care choices. Unbeknownst to them, their policy’s networks can significantly alter where they can receive covered (insured) care.
What are Health Care Networks?
The network is the health insurance carriers’ accumulation of facilities, providers, suppliers, and physicians they contract with to provide services to members. Each insurance provider normally has several different levels of networks; some networks are small and less expensive, and some are full (the entire network the carrier has) and more costly. Individuals often buy up into the more expansive network because they have a certain physician that has been in their family, a friend of theirs, or a physician they trust that is not in the smaller network (this happens mostly in HMOs since a HMO member can not go outside of the network and still be covered under their insurance carrier).
How to find Whom, What, And Where Your Network Contracts With?
The best way to understand a policy’s network is to either: go online to the carriers website and see what their network encompasses, ask your broker, or call the insurance carrier and find out from one of their customer service representatives. If you are purchasing health insurance from a broker and because there are so many different networks to choose from, it is best to tell your broker that you want a specific hospital and will not take an HMO that doesn’t include it. This helps the process out substantially because the broker will guide you through the plans that do have your specific needs in-network, but be aware, choosing to only use insurance carriers that contract with a specific hospital may limit your choices, potentially increasing your costs and decreasing your coverage (another point to bring up with your broker).
Finding the Network that works Best for You
If you are an employer and you are having trouble trying to find a network, or certain employees want to have a full network, you will be happy to hear that employees can have the option of “buying up”. Buying up is when an employer chooses a specific policy, and if certain employees would rather have the chance to have a better network, they can pay more for the fuller networks. Buying up is just another option that can help employees find the best plan that suites them, because a lot of times, employees will just keep the plans the employer choose for its cost sayings (employer contribution).
Staying in Network
If you have a PPO and you have the ability to either purchase a better network (such as the full network compared to a smaller network) but pay a higher premium, or chose to stay with the more limited network but occasionally go out-of-network to seek certain medical services, which would you chose? Hopefully I can help you out with that decision right now because I have seen problems arise when people choose to go out-of-network knowing full well they were going to beforehand (when they had the choice to have a full network) but thought choosing the smaller network would be more cost efficient (lower premiums). To begin, in-network services are going to cost the member less because the insurance carrier negotiated the prices. Along with this, there is no balanced billing that can happen in-network, which saves the member a lot of headache and money (click HERE to see what balanced billing is and how to avoid it). It is also usually much easier to plan your services ahead using in-network facilities and doctors because if you chose to go out of network, but have the a physician that is in-network, you may be slammed with unexpected fees (sometimes, people make sure the operating physician is contracted with their insurance carrier, but don’t realize their anesthesiologist isn’t, and from that, get balanced billed). Lastly, if you have a bad experience with any of the doctors in network, you can fill out a form explaining your experience with the doctor (which puts power into your hands). No contracted doctor wants to have a negative review (enough could cause disciplinary actions leading to a separations between them and the insurance carrier). Staying in-network is the way to go, and although PPO members have the choice to go out-of-network, I would advise against it (for cost saving purposes, including the extremely negative effects of balance billing).
Broker Tip: If you believe you are in a life threatening situation, you may go to the nearest emergency room with no out-of-network negative affects (this even goes for HMOs that have no out-of-network coverage). If it isn’t life threatening, you can always go to an urgent care that is in-network to get help.
I hope this has answered your question regarding networks, and by now you have a solid foundation of what a network is and how to save money by staying inside of yours. Have a great day, and thank you for reading!
Additional Disclaimer – Although I am an Insurance broker and a professional in the field, the Health Care laws are ever changing, especially in the age of the Affordable Health Care Act, and the laws, information, opinions, or understandings that I have wrote about may be obsolete by the time you come across them and I take no legal responsibility for what actions you may or may not take because of it. To keep yourself safe, please seek updated professional advice, because changes are happening and I would like to keep everyone safe from any misleading or dead information. Please check out the “Terms and Conditions” page for more information and/or bookmark my blog for upcoming changes and updates to the ACA. Thank you for reading, and have a great day!