Some Americans who were working with a variety of doctors for particular health conditions might now find that while some may be in the network of a new insurance plan, others may not. When selecting an insurance plan through the Marketplace, it is not easy to see what the expected costs are because networks are rarely disclosed, and the monthly costs alone don’t give the whole picture.

What is a Network?

A medical network is a group of providers that accept the insurance plans. Providers include general doctors, specialists, and hospitals, as well entities that supply products or services to a beneficiary, such as pharmacies, laboratories, and medical equipment providers. To join a network, a provider agrees to accept the insurance plan’s payment rate, which is lower than the non-negotiated rate. This allows the insurance company to offer customers lower costs, including copayments and deductibles, if they use providers within these networks instead of others. The providers who make this agreement are considered ‘in-network’ for the insurer.

A provider that does not accept the insurance plan’s rates is considered “out-of-network.” If you choose an out-of-network provider you will be subject to higher cost-sharing amounts. In fact, many times in the Marketplace plans, there is no coverage at all from the insurance if you choose to see an out-of-network provider.

As an insurance customer, you will need to make sure that you have the coverage you need for the providers that are important to you. If you have a specific family doctor, specialist, hospital or pharmacy you prefer, you will want to make sure they are “in-network” for the plan you choose if at all possible.

How to Find Network Information

Unfortunately, this information is not easily available to the public. There are two primary ways to find out who is in the network for a particular insurance plan. You can contact the insurance company directly and ask for the information, or you can contact the provider directly and ask which plans they are considered in-network for. The latter can often be the easiest course if you have a few key providers.

If you have several providers you work with, you may find that they are not in-network for the same plans. In that case, you will want to choose a plan that covers most of them, and make sure that plan also has coverage for out-of-network providers.

Cost and Networks

Many times an insurance plan that has a lower price will also have a narrower network. Studies have shown that the cheapest plans have narrow or ultra-narrow hospital networks.

However, keep in mind the plan with the least expensive premiums may not save money at all. If a cheaper plan does not cover the doctors you want or need, you will end up paying far more out-of-pocket than you would have if you had simply purchased a more expensive plan with a more appropriate network. In addition, you may find yourself wanting or needing to pay extra for a plan that offers out-of-network coverage, so that you can use the doctors you need for your health needs. Additionally, plans with lower premiums tend to have higher deductibles and higher cost-sharing.

Furthermore, just because a plan is expensive doesn’t mean it has a wide network. The study cited above also showed that the majority of plans with ultra-narrow networks weren’t the cheapest. So be sure to do the research to determine exactly who is covered in each plan to avoid unpleasant surprises when it comes time for treatment.

To make sure that you choose a coverage plan that includes your priority medical providers, contact the providers directly and ask them what networks they are part of. If you must use out-of-network providers, be sure to find a plan that offers a reasonable amount of insurance coverage for them. By doing so, you can ensure that the health care providers you prefer are part of your health care going forward into 2014. Another important decision to make, then, is whether or you anticipate a lot of health care spending (including medication). If you will need a lot of services, a platinum plan could be worth the higher premium.  If you won’t (which is always a bit of a guess), then the lower-coverage plans could be just fine.

 

Sources:

http://www.healthcare.gov/

https://www.healthcare.gov/can-i-keep-my-own-doctor/

http://www.fairhealthconsumer.org/reimbursementseries/installment_two.aspx

http://capsules.kaiserhealthnews.org/index.php/2013/12/marketplace-plans-networks-are-very-small-study-finds/