Network health insurance plans are some of the most common health plans, and as such, it’s important to be familiar with them. Whether you have a network plan or it’s an option, you should be familiar with what these plans are and how they work.
What is a Network Plan?
The definition of a network plan varies slightly by state, but they’re defined by the network. “Network” comes from the large group of physicians, hospitals, and other health care providers that have agreed to provide medical services to a health insurance plan’s members at a contracted rate. Often, the contracted rate is discounted from what providers charge patients who aren’t members of a contracted health insurance network plan.
Many different healthcare professionals, facilities, and organizations can participate in a network plan. Doctors in solo practice and who are part of groups can both participate, as can hospitals, clinics, outpatient centers, emergency clinics, and other facilities.
Pharmacies can also participate, although how much prescription medicines cost may depend more on a plan’s prescription drug coverage and a medication’s classification. Seeing an in-network pharmacy might be important if a drug isn’t covered well, as pharmacies charge different prices for medications.
Ancillary providers, such as chiropractors, acupuncturists, counselors, and other medical professionals less frequently participate in plans. Additionally, whether these providers are in-network only matters for plans that cover such services. Some health network insurance plans may have small networks of ancillary providers, though.
The comprehensive group of providers who participate constitutes the “network” part of a network health plan.
How Are Network Plans, PPO Plans, POS Plans, HMO Plans, and EPO Plans Different?
Network plans are characterized by the network of contracted providers. Beyond this, network health insurance plans don’t have a uniform method that patients must use to access providers. Other plan types can be thought of as subsets of net plans, with these subsets being defined by how patients are allowed to access providers:
- PPO Plans: Preferred Provider Organization health plans have a network of “preferred” providers. Patients receive discounts on care from these providers, compared to the cost of using a non-preferred provider. Patients can see any provider without a referral.
- POS Plans: Point Of Service health plans have a network of providers, from which patients receive discounts. Patients need a referral from their primary care physician to see any specialist who participates in the plan.
- HMO Plans: Health Maintenance Organizations have networks of providers that patients are required to use. These plans usually offer no coverage for non-contracted providers, except in emergency situations. Patients might also have to reside in an area that the HMO’s network covers.
- EPO Plans: Exclusive Provider Organizations have networks of providers that patients are required to use. These plans usually offer no coverage for non-contracted providers, except in emergency situations.
What Does In-Network Mean For Your Health Plan?
Providers who are in-network participate with your health network insurance plan. They’ve contracted to provide services at set rates. The contracted rates are normally renegotiated annually.
You’ll typically receive the most affordable care if you use in-network providers, regardless of what type of health plan you have. If you’re unsure whether a provider is in-network, you can ask their office whether they accept your insurance, or ask your insurance company for a list of in-network providers.
Is In-Network The Same As PPO?
In-network and preferred provider organization are distinct terms, and refer to different aspects of a health insurance plan.
A PPO is a type of plan that has a network of “preferred” providers. In-network references whether a provider participates in a health plan network. Thus, you can be in-network (or out-of-network) with a PPO. Although PPO uses the term “preferred,” there’s generally no functional difference between in-network and preferred from a patient’s perspective.
What Does Out-Of-Network Mean For Your Health Insurance Network?
Providers who are out-of-network don’t participate with your health insurance network plan, and they have no contracts that guarantee services at set prices.
Providers can be out-of-network for a few different reasons. Some simply might not be satisfied with your plan’s reimbursement rates for services offered. Others might not be in the geographic area that your plan covers, especially if your plan is an HMO or state-sponsored plan. In certain cases, providers might not participate with smaller plans because of their size.
You can usually expect to pay higher rates if you choose an out-of-network provider, and the difference between out-of-pocket costs for in-network and out-of-network providers can be substantial. Not only are out-of-network providers not contracted at set prices, but most plans also provide reduced coverage for out-of-network care. Your plan may offer lower coverage rates or no coverage whatsoever if you go out-of-network.
There are a couple of possible exceptions to the general rule that out-of-network care costs more. First, most plans provide coverage for true medical emergencies regardless of network. The thinking is that you shouldn’t have to drive to an in-network provider if you need emergency care (e.g. care that would justify calling 911). Second, occasionally you can get in-network coverage for out-of-network care if there’s no in-network provider within a specified distance (e.g. 100 miles) of your residence. The second exception isn’t as common.
Health Plan Network Final Notes
You likely have or have access to a network health insurance plan that’s defined by its network of providers. If you do, make sure you know what providers are in-network so that you can find the most affordable care.
For help finding a policy that has a robust health plan network in your area, use eHealth to explore your options. eHealth has many medical insurance network plans available to choose from, and has helped pair many individuals and families with the network plan that is best for them.
eHealthInsurance offers thousands of health plans underwritten by more than 180 of the nation’s health insurance companies, including Aetna and Blue Cross Blue Shield. Compare plans side by side, get health insurance quotes, apply online and find affordable health insurance today.