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Information on Health Insurance Provider Networks

Information on Health Insurance Provider Networks

Below you can find answers to frequently asked questions on health insurance provider networks.

What is a home health care or skilled nursing facility provider network?

A provider network is a list of the home health care agencies or skilled nursing facilities that an insurance plan has contracted with to provide medical care to its members. These providers are called “network providers” or “in-network providers.” A provider that hasn’t contracted with the plan is called an “out-of-network provider.”

How do different types of insurance plans use provider networks?

Depending on the type of plan you buy, your care may be covered only when you see a network provider. You may have to pay more, and/or get a referral if you choose to get care from a provider who isn’t in your plan’s network.

Types of plans include:

  • Preferred Provider Organizations (PPOs): PPOs give you the choice of getting care from in-network or out-of-network providers. You pay less if you use providers that belong to the plan’s network. You’ll pay more if you use doctors, providers, and hospitals outside of the network, and you may have higher out-of-pocket costs for services. If you have a PPO plan, you can visit any doctor without getting a referral.
  • Point-of-Service (POS) Plans: POS plans let you get medical care from both in-network and out-of-network providers. If you have a POS plan, you’ll choose a primary doctor from a list of participating providers. Your primary doctor can refer you to other network providers when needed. If you want to visit an out-of-network provider, you’ll also need a referral and you may pay higher out-of-pocket costs. n Health Maintenance Organizations
  • (HMOs): HMOs usually limit coverage to care from providers who work for or contract with the HMO. An HMO generally won’t cover or has limited coverage for out-of-network care except in an emergency. If you use a doctor or facility that isn’t in the HMO’s network, you may have to pay the full cost of the services you get.
  • Exclusive Provider Organizations (EPOs): EPOs generally limit coverage to care from providers in the EPO’s network (except in an emergency).

Why do some plans cover benefits and services from network providers, but not out-of-network providers?

When a provider is a network provider for a plan, it means that the provider agreed to provide benefits or services to the plan’s members at prices that the provider and the plan agreed on. The provider generally provides a covered benefit at a lower cost to the plan and the plan’s members than if providing the same benefit to someone without insurance, or someone with insurance through a plan in which the provider is out-of-network.

Learn more about insurance coverage for the follow provider types


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