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Is your physician in a health plan’s network?

It is a question that you should know the answer to because receiving healthcare services from a provider in a health plan’s network saves you money, sometimes a considerable amount of money. However, far too many of the insured in the United States either do not bother to determine whether a healthcare provider is in a health plan’s network or they do not understand how a health insurance network works.

Receiving healthcare services from a provider in a network reduces the out-of-pocket costs that are associated with different types of medical care. Does cost savings represent the only thing you need to understand about your health plan’s network?

Let’s review the basics of a health plan’s network to help you make the best decision for buying the right health insurance policy.

Overview of Health Plan Networks

Healthcare providers represent a group of clinicians, hospitals, and physicians that health insurance companies work with to provide healthcare services at a rate negotiated by both parties. When you select a health insurance plan, you want to choose one that allows you to see your preferred provider at the most affordable rate. If you choose a healthcare provider that is in a health plan’s network, healthcare services cost you less money than if you seek medical care outside of a health plan’s network.

Staying within a health plan’s network is an especially important factor for consumers that purchase health insurance during the annual enrollment period established by the Affordable Care Act (ACA)

What Are the Types of Healthcare Networks?

You have four primary types of healthcare networks to choose from when you shop for the most affordable policy that delivers the most comprehensive healthcare services.

  • Exclusive Provider Organization (EPO)
  • Health Maintenance Organization (HMO)
  • Preferred Provider Organization (PPO)
  • Point of Sale (POS)

The biggest differences between the four types of healthcare networks regard the extent of sharing costs and where you can receive coverage.

Learn more in Choosing Your Health Insurance Network: HMO or PPO?

Exclusive Provider Organization

An EPO represents a type of healthcare network in which the insurance company shares the cost of coverage only when a policyholder visits healthcare providers that are listed in the network. This means that if you seek medical care from a physician outside of the network, you assume responsibility for paying the entire healthcare bill. The only exception to the all-or-nothing payment model is in cases when policyholders face a medical emergency. If you receive emergency medical care with an out-of-network healthcare provider, your insurer must share the costs of the emergency medical care.

Health Maintenance Organization

Considered the budget-friendliest type of healthcare network, an HMO network policy provides coverage just for the healthcare providers that are part of the HMO. The HMO model operates in the same way as an EPO, with one major exception. An HMO allows a policyholder to include integrated care, such as wellness and prevention programs, as a part of the network. For policyholders that require special types of medical care, the additional healthcare services represent an appealing selling point to buying an HMO health insurance policy.

Preferred Provider Organization

A PPO works like an HMO and EPO by offering cost-sharing benefits if you remain in-network when receiving medical care. However, a PPO differs from an HMO and EPO because if you go outside the network for healthcare service, your health insurance plan shares some of the costs that are associated with medical care delivered by an out-of-network healthcare provider. Another strong selling point of enrolling in a PPO is you do not need to get a referral to receive healthcare services from a specialist. With the other three major types of healthcare networks, you first must gain approval to see a specialist from your primary healthcare provider.

Point of Service

POS networks require policyholders to get permission from their primary healthcare providers to visit with specialists, such as a cardiologist. Like a PPO, a POS health insurance policy allows you to go outside the network to receive medical care without assuming responsibility for paying for all the costs associated with healthcare services. However, you pay more in monthly premiums for the option to go outside the health insurance network.

The Bottom Line

Deciding on the right health insurance plan and healthcare provider network requires a delicate balancing act between costs and your healthcare needs. For example, if you need to visit with a specialist frequently, then maybe enrolling in a PPO plan is the best option for your unique healthcare requirements. On the other hand, if you do not need to visit with a specialist frequently, enrolling in an inexpensive HMO plan might be your best option.

You also have to consider the status of your health. If you are healthy and do not expect to need any major medical procedures in the foreseeable future, enrolling in a reduced-cost health insurance network makes sense.

If you need assistance navigating all of these options, Insurance Broker Hub can help. Our free service gives you access to an independent network of national brokers who have the experience and expertise to design a plan around your needs and budget. Ready to get started? Simply request a no obligation health insurance quote here.