Health insurance counseling

Provider networks: What to know

Selecting a health insurance policy is a major life decision, especially for people with chronic illness. And it’s not too early to start considering your options for 2018. The open enrollment period is on the horizon. The health insurance marketplace enrollment period runs 45 days:

Open enrollment periods

During an enrollment period, you can enroll in new coverage, or change your existing coverage.

  • Medicare: Oct. 15-Dec. 7.
  • Health insurance marketplace: Nov. 1-Dec. 15.

While many focus primarily on premium and deductible costs, the provider networks within an insurance plan are also important but commonly go overlooked.

What is a provider network?

Provider networks are essentially lists of doctors, hospitals and other health care professionals or facilities that an insurance plan covers. The networks are established from contracted agreements made between insurance providers and health care professionals to offer services at lower costs. They determine whether or not a health care provider accepts your health insurance policy.

Insurers design these networks to help them control costs. But to meet Affordable Care Act (ACA) requirements for qualified health plans, the networks must follow state and federal regulations meant to ensure consumers have an adequate choice of health care providers inside those networks for most insurance offerings, which should ultimately promote a healthy and competitive market. Still, problems exist, notably dated or inaccurate provider directories that result in unexpected charges for consumers.

So what does this mean for you?

If you intend to change your plan in 2018 and wish to keep seeing the same doctor—especially if you are insured through health insurance marketplaces or Medicare Advantage—provider networks are important.

Exercise foresight and carefully evaluate the existing network and specialists before selecting a policy. Ask yourself if the plan you’re considering will suit both your current and future needs.

For example, you may be drawn to a Health Maintenance Organization (HMO) plan because the premiums tend to be lower. (See “Health Insurance: What’s the Difference?” below for more about plan types.) However, in HMOs, insurers have a strict provider network, increasing the chance you cannot see your current providers. If your doctor or provider did not contract with the insurer, they will be considered out-of-network and your plan won’t cover their services.

With the recent rise in health insurance premium costs, you may be faced with a difficult choice. In spite of this, you can be proactive and take the following steps to learn about a policy’s provider networks to ensure you select the plan that best suits your needs.

  1. Visit the insurer’s website and peruse their provider directory. If you do select the plan, print or download a copy to keep handy in case an issue arises in the future.

Note: The ACA requires health insurance companies to publicly publish their provider directory every year and for each offered plan, update it anytime they make changes, and ensure it is easily accessible. If you have trouble locating a directory, this should raise a red flag.

  1. If you’re shopping for available plans online with the marketplace, search for and add your providers and prescriptions when prompted. The resulting plans will note whether or not your doctor is in-network, but don’t rely solely on this tool since the directories can be out-of-date. Double check with your provider or insurance company once you’ve found a plan you like.
  2. Search your provider’s website for accepted insurance. It can be tricky to locate, but try using the search bar. Type in the word “insurance,” and the results could direct you to the provider’s accepted insurance policies or at least provide information about who to call for insurance questions.

Note: One thing to keep in mind if you are looking at a hospital health group: It’s possible the hospital accepts the insurance, but your specialist affiliated with the hospital does not. Call to find out.

  1. Call your provider, which is the most direct approach.

If you directly contact your doctor’s office, you can ask them what insurance plans they are participating with this year. They should be able to give you the information they have at the time, but keep in mind they may still be in contracts with insurers. Contracts can fail at some point, and ACA laws should provide a buffer if that occurred.

  1. Call the insurance provider and have the representative check if your doctors are in-network. They should have the most up-to-date information in their databases, but you still want to be cautious. Make sure you provide the correct spelling of the doctor’s name and know their most current location.

A few things to note

  • Provider networks can change at any time. The reasons can vary. For example, the provider can choose to leave the network.
    • This does not mean you can change your plan. Once open enrollment ends, you can only change plans if you qualify for a special enrollment period, based on certain life events or situations.
    • You can file an appeal with your insurance provider to see if they can make an exception. Contact your plan for instructions.
  • If you are unable to make your insurance options match with your preferred providers, ask your current doctor if he or she can recommend a colleague that may accept your insurance.
  • As a last-ditch effort, you can ask your doctor if they will allow you to see them at full cost.
    • Check with your provider if they offer a “cash-only” option. If they do, you can make arrangements to see your doctor a few times a year at full cost, so that you’re still under their care.
    • Check whether the provider offers financial assistance.
  • In 2018, if you receive qualifying essential health services from an ancillary, out-of-network provider at an in-network facility, such as a hospital—unless the insurer notifies you within 48 hours that you may incur an additional charge before you undergo the treatment—insurers must apply the amount you pay for the out-of-network provider towards your in-network out-of-pocket maximum.

See also: Health care glossary

Health insurance types infographic with provider networks

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