Affordable Care Act
Many of today’s health insurance plans utilize “provider networks.” It’s important to know what these are and how to use them if you want to get the most from your health insurance dollars. In this article we answer the following questions:
VIDEO: How are Obamacare’s provider networks like a secret handshake?
The answer is simple: Money. Receiving medical care from an out-of-network doctor or hospital can cost you hundreds or potentially even thousands of dollars more than seeing an in-network doctor or hospital. In an eHealth survey of more than 6,500 customers, at least 1-in-5 of those who received medical care saw an out-of-network doctor. On average, these people spent nearly $900 more on their care than those who paid out of pocket for care from network doctors.
A provider network is a group of doctors or hospitals that enters into a contract with a health insurance company. Most doctors and hospitals have network contracts with more than one insurance company. Doctors and hospitals like provider networks because they help guarantee a steady stream of patients. In return, they agree to offer the insurance company’s members a reduced price for the medical care they receive.
Having access to a provider network through your insurance plan is kind of like knowing a secret handshake or being part of a special club. It gives you a list of doctors and hospitals that are willing to see you at discounted prices for care. Let’s look at an example to illustrate the concept. This is just an example, of course. The real dollar figures involved may vary. Say your local doctor generally charges $250 for an office visit. That’s what you would pay if you just walked in off the street without health insurance. If you’re insured and the doctor is part of your provider network, however, you may only be charged $120 for that visit. Depending on how your insurance plan works, some part of that $120 may be paid by you and some part may be paid by the insurance company – but once a total of $120 is received, the network doctor will consider your bill paid in full.
Getting medical care from a doctor, lab, or hospital outside of your insurance company’s provider network can cost you a lot of money. In the example given above, seeing this doctor without the benefit of a network relationship could mean that you’re on the hook for the full $250! Even if you have coverage, your insurance company may not contribute anything toward care rendered by providers outside their network.
This is a common question. Is a non-network specialist automatically covered by your insurance company because you were referred to the specialist by an in-network doctor? The answer is No. In the end it’s up to you – not your doctor – to make sure that any specialists you see or hospitals you visit are in your insurance company’s network. Luckily, most insurance companies have great online resources to help you find doctors and hospitals that are in your network. They can also confirm the network status of any doctor or specialist you might like to see. Remember, insurance companies regularly change which doctors, specialists, and hospitals are in their network, so make sure you get the most current information.
Most health insurance plans make some exceptions for network rules in case of emergency. The extra out-of-pocket costs you might have faced for receiving non-network care is often waived in emergency circumstances. Be aware, however, that once you’re discharged from the emergency room any additional care you may receive from the same non-network health care providers – even if it’s related to what you were seen for in the ER – may not be covered. Ask your insurer or licensed agent about how your plan works in emergency situations.
Anytime you’re shopping for a new health insurance plan, make sure you pay special attention to the provider networks offered to you. Will you have access to doctors and hospitals nearby? How far are you willing to drive to see a network medical provider? If you have a favorite doctor that you want to keep visiting – and many of us do – then you’ll also want to check his or her network status when considering any new health insurance plan. Articles like this can only provide general information, so be sure to familiarize yourself with the benefit details of any plan you are considering to decide if it suits your individual needs. If you want assistance, a licensed health insurance agent can help you find a new plan that meets your needs and budget and that gives you access to the doctors you want to see. eHealth has great online resources to help you check which plans are accepted by your favorite doctors.
When you shop for coverage at eHealth.com during the 2016 open enrollment period, you’ll get:
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