In or Out of Network? Primary Care of Specialist? HMO or PPO?

 Throughout your life, you will change insurance carriers many times. Sometimes you lose or gain eligibility due to a career change. You may age into Medicare eligibility, you may marry or divorce, may choose to join a plan on the Healthcare Exchange, or may become disabled and eligible for your state's Medicaid or Social Security benefits. Depending on the type of insurance, you may be able to change your plan every year, or you may have to wait until you have a qualifying life event. 

Each time your benefits change, you are faced with the same series of questions and considerations. Is your regular physician in your new network? Do you need to get a new referral to continue to see your allergist or cardiologist? Will your deductible be higher or lower? Are your medications still covered? What is your new copay for regular visits? Can you go to the emergency room if if it's necessary? 

First it's necessary to understand the difference between an in-network provider (INN) and and out-of-network provider (ONN). Provider in this instance may be a doctor, a member of the doctor's team, the doctor's entire group or clinic, or the facility like a hospital or an out-patient surgical center. Sometimes the hospital may be in your network, but the specialist who prepares you for surgery is out of network. At times, you can double-check to make sure every provider on your team will bill as in network, and other times, there is no way to double-check before a procedure. 

When you are changing health insurance carriers or plans, always be sure to check the network providers. If you have a preferred primary physician and you don't want to seek a new one, stay away from Health Maintenance Organizations (HMO), which can tightly restrict your choices. Instead, it may be worth it to pay slightly higher premiums to join a Preferred Provider Organization (PPO) plan that will allow you more liberty to choose your providers. 

Primary care physicians tend to be general practitioners, OB/GYNs, or internists. Specialists are doctors who have specialized in one particular area, like cardiologists, allergists, and dermatologists. If you have specific health needs that require specialized doctors, it's important to understand the difference between an HMO and a PPO. In an HMO, a referral from your primary care physician may be necessary, even if you have been seeing your specialist for years. Once again, choosing to pay slightly higher premiums can be valuable in maintaining your standard of care. 

Are you changing insurance plans and have questions about how your new plan works? Have you lost or gained eligibility recently and need help understanding the literature you've received about your plan? We're happy to help you read and interpret your new plans information. Email us today with your questions.