Understanding Provider Networks

As you explore your health insurance options, you’re often bombarded with lingo and jargon that can be confusing. To understand what plan benefits are available to you, and to compare policies for coverage and costs, you may need help understanding a few of the industry’s many complexities. Some of the most frequently asked questions revolve around understanding provider networks. And if you find yourself having a similar train of thought, with some confusion about what they are, how they’re determined, and what they mean to you, stay tuned. We’ll help peel back the onion and shed light on everything you need to know about provider networks.

What Are Provider Networks?

Let’s begin with the basics. When you see provider networks listed online or hear others talking about their provider networks, the term might have different meanings. It may be helpful to first carve out what provider networks are and what you need to know about them as you shop for health insurance plans.

Official Definitions
Provider networks are the lists of various healthcare providers, including doctors, specialists, and hospitals, that are contracted by a specific insurance company. Those providers are sometimes referred to both “in-network providers” as well as “network providers.” When you see plans that have what they call “managed care,” it means the insurance company has those “in-network providers.” It’s helpful to understand these terms as you shop for new health insurance plans. And it’s becoming more popular for plans to promote healthcare provider options for individuals, so you’ll more than likely see these terms more frequently within the Marketplace.

Why Do Insurance Plans Have Provider Networks?
According to America’s Health Insurance Plans (AHIP), insurance companies can leverage their provider networks to make their offered health plans more cost-effective. The health care providers that are considered “in-network” will often charge lower rates for their services, in exchange, of course, for being part of the insurance company’s provider network. This is why individuals pay more and see higher bills with out-of-network providers.

Why Individuals Should Pay Attention to Provider Networks
You may be wondering why you should pay attention to provider networks. When evaluating the various health plans available to you, those provider network guidelines will translate to out-of-pocket costs to the individual. For example, if your primary care physician is part of a particular policy’s provider network, you can see more affordable prices. On the other hand, if your healthcare professional is not part of a plan’s network, it may cost you more for services. Understanding provider networks will help you, in turn, control your medical costs and avoid costly surprise health bills down the road.

What Types of Provider Networks Are There?

You understand provider networks as they apply to in-network partnerships. But there are other types and nuances that may affect your coverage and costs. As you navigate the health insurance options, you may see some of these other provider network types listed, as well. An Exclusive Provider Organization (EPO), for example, will only cover expenses associated with designated healthcare providers. If you have a doctor you’d prefer to see regularly, a plan type like the EPO might not be a good fit.

Preferred Provider Organization (PPO)
Some Marketplace plans will suggest you use their preferred providers as part of their provider network. This is considered a Preferred Provider Organization. There may be flexibility offered for those individuals who choose to use healthcare professionals or medical facilities outside of the network. However, it may mean the insurance plan will cover less of the billed services.

Health Maintenance Organization (HMO)
Health Maintenance Organizations will typically have lower monthly premiums, making them attractive to budget-conscious individuals. But these types of plans can be more restrictive in terms of choosing a health care provider. Many will only cover the primary care physician’s referrals directly.

Point of Service (POS)
If you were to create a hybrid model of the PPO and HMO style of plans, you’d have the Point of Service model. Similar to the guidelines of the HMO, you might have to choose from a designated list for your primary care physicians. But like the PPO offerings, you’re not exclusively restricted to the one provider and referrals. With the Point of Service plan, you can select a healthcare professional outside the provider network but may pay a little more to do so.

Provider Networks & Choosing a Marketplace Plan

Understanding provider networks and what they are can help as you select a new health insurance plan for yourself or your family. It may bring you to your next question. How do you use this knowledge to your advantage as you browse available plans? Start with identifying what your health insurance needs are, and you can source available plans for consideration.

How to Tell the Various Types of Plans in the Marketplace
When you browse the various health plans on the Marketplace, you’ll want to pay attention to what type of plan you’re viewing. Typically listed directly below the actual name of the health plan, there are acronyms to identify the plan type. You’ll see if the coverage is PPO, POS, or HMO there and within the plan’s Summary of Benefits and Coverage page. If you’re unclear about a plan’s details or need assistance understanding provider networks associated with the plan, don’t hesitate to contact the insurance company with questions.

Know Your In-Network Providers
Each insurance company has its own roster of healthcare providers as part of the provider network. Finding a plan type that works for you is only half the battle. Take your search a step further by searching for your doctors, hospital facilities, and specialists within those networks. Consider starting with a shortlist of you and your family’s trusted professionals first, so you know who to look for within those provider networks.

Open Enrollment for 2021 Coverage
Open Enrollment for Marketplace coverage in 2021 is fast-approaching. The open enrollment period will begin Sunday, November 1, and will remain open through December 15, 2020. Mark your calendars and set reminders for yourself to ensure you don’t miss this period. Any plans selected during this time will begin coverage as of January 1, 2021.

Understanding provider networks can make selecting the right health insurance plan easier. And to make the browsing and comparison-shopping process even more seamless, W3LL can help. Health insurance details can be complicated to understand, even beyond provider networks. So when you need expert guidance to help you shop and crunch costs, the W3LL professionals are available to assist. Our free service puts all the necessary tools at your fingertips, allowing you to make quick and efficient work of selecting your 2021 health insurance coverage.

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