4 Things to Look for in Your Health Insurance Plan: #2 is the Network

What should you look for in a plan?

1) Max Out-of-Pocket

2) Network Types: PPO, HMO, EPO, POS

3) Monthly Premium

4) Deductible

Why is the Network type important and what are they?

If the provider accepts the insurance plan then the provider is considered "In-Network". If the provider does not accept the insurance plan then it would be considered "Out-of-Network" which either means that no coverage is offered or it is more expensive. (Providers are doctors, hospitals, facilities, etc.)

When the provider is considered In-Network then the insurance company has a contract with the provider. Typically, the contract includes pre-negotiated savings when their insurance is used.

For instance, a doctor typically charges $150 on average for a doctor's visit. If your doctor is in-network, the bill could be brought down by $60 just for using a contracted doctor.

The negotiated rate is also called a called an In-Network discount, or a re-pricing.

Example:

Now that we understand what networks are - let's talk about the different types of networks. The four network types are:

PPO: Preferred Provider Organizations

HMO: Health Maintenance Organizations

EPO: Exclusive Provider Organizations

POS: Point-of-Service plans

PPO

PPOs are the best network since they offer the most freedom. You have a large, national network. You have the freedom to choose your doctor. You do not have to have a referral from your doctor to see a specialist. You have coverage for Out-of-Network costs. Therefore you have peace of mind that you won't have to go bankrupt just for being out of your state.

HMO

HMO's are restricted to typically your state or county. You can only use providers that are In-Network. The only exception is for emergencies then HMOs will provide coverage for the emergency care. You also have to have a primary doctor. HMOs require referrals from your primary in order to see a specialist. Your primary is the funnel for care.

EPO

EPO's are a national network but have a shorter list of approved providers. It's also limited since it only offers coverage for In-Network providers. EPO's vary when it comes to having a primary or needing a referral.

POS

POS networks are a type of hybrid. It requires a referral to see a specialist. The network is typically restricted to the county or state you live in. However, it does offer Out-of-Network coverage.

On the Public Marketplace/ObamaCare:

HMOs are the most common and typically the most affordable. EPOs are the second most common and are priced similarly to HMOs. PPOs are harder to find since most states only offer HMO's, EPO's and sometimes POS's. PPO's are also the most expensive on the marketplace.

On the Private Sector/Non-ObamaCare:

PPO's are more common and more affordable than the marketplace. Typically all four networks are offered through the Private Sector but it is dependent on the state.

Example Scenarios:

1) You have a rash on your arm and it's starting to spread. If your plan requires a referral (HMO/POS) then you have to schedule an appointment with your primary for him to look at the rash and agree that you need to see a dermatologist. (Hopefully, the rash doesn't spread between now and your appointment with your primary.)

With a (PPO/Some EPO's), when you know you need to see a specialist - you can go right to the specialist.

2) Let's say you fly out to see your dad in Vermont over the holidays. And while you're there, you slip on black ice and break your tailbone.

• If you're on an (HMO), then it looks like you'll be forking up the money to pay for everything, or you're hopping back on a plane to go home to get the x-rays/treatment/ pain medication, etc.
• If you're on an (EPO), you'll want to call your insurance to see if there are any In-Network hospitals that are able to see you. You may have a long drive but that's okay. However, if you can't find or don't have the ability to go to an In-Network provider then you're likely to be the one paying the full bill.
• If you're on a (POS), the good news is that you'll have coverage - it'll be really expensive but chances are that you won't be paying 100% of the bill.
• If you're on a (PPO), then no worries since it's easy to find a hospital that's In-Network.

Summary:

Overall, you'll definitely want a PPO network. They're harder to find since most are through the Private Sector. Reach out to me and I can show you your available options. My direct line is (813)644-0406

Disclaimer: All plans are created differently. Some insurance plans actually include some type of safety net if you're Out-of-Network. It's absolutely CRUCIAL that you look at the plan's limitations & exclusions.

Nothing but love,

Agent Gina Knight

Senior Licensed Advisor

Here to help protect you, your family, your health & your assets.

Direct: (813) 644-0406