A network is a group of providers (hospitals, doctors, laboratories, etc.) who have agreed to provide their services at reduced rates. Out-of-network means that you are using a provider that is not part of the network.
An HMO (Health Maintenance Organization) requires that all services be done by network providers. There is no option to go out of network. When you have an HMO, you must choose a primary care physician (PCP). This physician will manage all of your medical care and provide you with referrals to specialists that are in the HMO network, when it is necessary for you to see a specialist.
A POS plan (Point of Service) works like an HMO with one major exception-- you do have the option to go out-of-network. You choose a primary care physician and the plan works exactly like an HMO, as described above. However, you do have the option to seek care out of the network. There is usually a deductible that must first be met, and then the plan will pay a certain percentage, ie, 70 % or 80 %. The plan is most cost effective if you remain in the network, but, you do have the option to use out of network providers when you deem it necessary.
A PPO or Preferred Provider Organization insurance plan does not require the use of a primary care physician. You may see any provider in the network. Most PPO plans have a co-payment or a very small percentage that you pay when you use network providers. When you go out of network, there is usually a deductible and a higher percentage that you must pay out of pocket. No referrals are needed, you choose any doctor, any specialty from the network providers. This type of insurance plan gives you the most amount of freedom and usually the largest networks.
It should be noted that most insurance carriers will provide you with a directory of network providers, but these directories are obsolete the day they are printed. Providers are joining and leaving networks throughout the year. The best way to determine if your provider is in the network is to call the office and tell them which type plan you have (HMO, POS, PPO) and ask if they participate in that particular network. Another excellent option to help you choose a provider is to check the website for your insurance carrier. All of the major insurance carriers have their providers listed on the websites. For example, Horizon Blue Cross/ Blue Shield of New Jersey website is www.horizon-bcbsnj.com. The Oxford website is www.oxfordhealth.com. You can call your insurance agent or the 800 # on your ID card to find out what the website address is for your particular insurance carrier.
Medicare does not utilize networks. If you are eligible for Medicare benefits, you can go to any doctor, any hospital, any laboratory, anytime of the day or night, anywhere in the U.S.A! It couldn’t be easier! No 800 # must be called, no referrals are needed. You simply make your appointment and show your ID card.
Irene Card & Betsy Chandler share the responsibilities of running Medical Insurance
Claims, Inc. a health insurance services company. If you have questions relative to this
column or other related topics, we invite you to call (973) 492-2828, browse our
past columns on our web
site at
www.micinsurance.com.
* * *
All content copyright © 2002 Medical Insurance Claims, Inc. unless noted otherwise. All rights reserved.