When choosing a health insurance plan, most people focus on the monthly premium, deductible, copays, and out-of-pocket maximum. But there is another important factor that is often overlooked: whether your doctors and hospitals actually accept the plan you are choosing.
One of the biggest misunderstandings about health insurance is assuming that because a doctor accepts a particular insurance company, they automatically accept every plan that company offers.
Unfortunately, that is not how health insurance works.
A doctor may accept one plan from an insurance company but not another, even when both plans are offered by the same company.
Understanding how provider networks work can help you avoid unexpected medical bills and the frustration of discovering that your doctor is not covered under your new insurance.
What Is a Provider Network?
A provider network is a group of doctors, hospitals, specialists, and other healthcare providers that have agreements with an insurance company to provide medical services to members of specific health plans.
Insurance companies negotiate contracts with healthcare providers, and those contracts determine which plans the providers participate in.
The important thing to understand is that these agreements do not necessarily apply to every plan offered by the insurance company.
For example, a doctor may accept an insurance company’s employer-sponsored plan but not its ACA Marketplace plan. The same doctor may also accept one Marketplace plan from that company but not another.
This is why asking a doctor’s office, “Do you accept Blue Cross?” or another insurance company is not always enough.
The better question is, “Are you in-network with my exact health insurance plan?”
The Difference Between an Insurance Company and a Plan
Think of an insurance company as a business that sells several different products.
Two people may have insurance through the same company but have completely different provider networks, benefits, and coverage rules.
One person may have access to a large network of doctors and hospitals, while another person with the same insurance company may have a much smaller network.
This is especially important with ACA Marketplace coverage, where insurance companies may offer several plans with different networks.
Even the metal level of a plan, such as Bronze, Silver, or Gold, does not guarantee that the same doctors participate in each plan.
What Happens If Your Doctor Is Out-of-Network?
The financial consequences can be significant.
If your doctor is not in your plan’s network, the insurance company may pay less for your visit or may not cover the visit at all.
The result depends on the type of health insurance plan you have.
HMO and EPO plans generally do not cover routine out-of-network services, except for certain situations such as emergencies.
PPO plans generally provide some coverage for out-of-network care, but your share of the cost may be substantially higher.
This means you could be responsible for the entire bill simply because your doctor does not participate in your particular plan.
There are federal protections for certain emergency services, but those protections do not mean you can routinely visit any doctor or hospital without considering your network.
Why Your Doctor’s Network Can Change
Another thing consumers should understand is that provider networks can change.
A doctor who accepted your insurance last year may not accept it next year.
Insurance companies and healthcare providers renegotiate contracts, and sometimes those agreements end.
Doctors may leave medical groups, change hospital affiliations, relocate, or stop participating in certain insurance networks.
This is particularly important during Open Enrollment.
Just because you are keeping the same insurance company does not guarantee that every doctor and hospital you currently use will remain in-network for the upcoming year.
How to Check Before Enrolling
Before choosing a health insurance plan, take a few minutes to verify your healthcare providers.
Start by checking the insurance company’s provider directory for the exact plan you are considering.
Then contact your doctor’s office and ask whether they participate in that specific plan and network.
If you regularly see specialists, check those providers as well.
You should also verify your preferred hospitals, particularly if you have an ongoing medical condition or anticipate needing treatment.
Keep in mind that insurance company provider directories are not always completely accurate or up to date. That is why checking directly with both the insurance company and the doctor’s office is a good idea.
A Few Minutes Can Prevent a Big Surprise
Imagine enrolling in a new health insurance plan because it saves you $75 per month.
You assume your doctor accepts it because the doctor’s office has always accepted insurance from that company.
A few months later, you schedule an appointment and discover that your doctor does not participate in your specific Marketplace plan.
Now you may have to find a new doctor, transfer medical records, or pay for the visit yourself.
The money you saved on your monthly premium may not seem like such a good deal anymore.
Bottom Line
Choosing health insurance involves more than comparing premiums, deductibles, and copays.
Your provider network is just as important.
Before enrolling, make sure your doctors, specialists, and preferred hospitals participate in the exact plan you are considering.
Do not assume that having the same insurance company means having access to the same doctors.
A good health insurance agent should help you understand these differences before you enroll.
The goal is not simply to find affordable health insurance. It is to find coverage that gives you access to the medical care you need at a price you can afford.
Because having health insurance is important, but being able to use it with the doctors you trust is just as important.