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In-Network? Out-of-Network? Get the Facts and Understand How it Affects YOU!

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In-Network? Out-of-Network? Get the Facts and Understand How it Affects YOU!

What Is an Insurance Network?

An insurance network is a term used to describe a group of: Doctors, Hospitals, pharmacies, labs and various other health care providers who have all agreed to provide services to members of a health insurance plan at a negotiated rate.  These health care providers are called Network Providers, more specifically, “in-network providers”.

When visiting in-network practitioners or facilities, usually, the standard copay fees and deductible amounts apply.

YOCG Wednesday 12 16 15Out-of-Network providers are those doctors and facilities who do not participate in your insurance plan’s network agreement.  Using providers who do not participate in your plan’s network may cost you in various ways.  For example they may:

  • Charge more that the negotiated rate your insurance plan negotiated with the in-network providers,
  • Require higher copays, deductibles and co-insurance fees
  • Or your plan may not cover anything related to out-of-network care

HMOs and PPOs

Now that you understand the difference between in-network and out-of-network, it is important to understand what HMOs are versus a PPO.

HMO is an acronym for Health Maintenance Organization.  Here re some quick facts about HMOs:

  • HMOs usually provide lower premium payments and copays
  • You are required to choose a primary care physician
  • You may choose a doctor from a list that is provided to you by the HMO. Most times there are no out of network benefits.
  • The doctor you select will help you manage your healthcare by referring you to specialists when needed

YOCG Tuesday 12 29 15 CANVAPPO is an acronym for Preferred Provider Organization.  Quick facts about PPOs are

  • You are not required to designate a primary care physician
  • You have more choices about who you can pick as a healthcare provider
  • If will cost you more for having the ability to choose your healthcare provider
  • Higher costs come in forms of higher premiums, deductibles and copays
  • PPOs also require you to select providers within a network and sometimes there are out of network benefits.

What are Referrals and When are they Necessary?

Referrals are a key part of HMO programs.  They assist your primary care physician (PCP) track your health care and ensure that you are receiving the proper care for your health condition.

Referrals are required when you need to see a specialist. The specialist your PCP sends you to, is usually a part of a circle of providers he trusts to give you the care that is outside of his practice capabilities.  It is always important to make sure that the specialist in in your HMO’s network.  Once you have a referral, you also have the ability to choose your own specialist to go to as long as they are in the network.

What About Emergencies?

What happens if you are in an emergency and need medical care right away?  There are some key points you need to know:

  • All plans include emergencies into to their coverage, even if you happen to be out of network when the emergency happens.
  • Once your condition is stable, you will then be transferred to an in-network provider for follow up care.
  • ER visits may incur an additional fee or cost in addition to your deductible.  Walk-in clinics are a good alternative and will save money is many situations.

YOCG Thursday 1 28 16 CANVADid You Know?

When navigating HMOs and PPOs there are some interesting facts and tidbits you need to be aware of so you are not caught off guard:

  • Did you know that your Doctor can choose to leave the insurance companies network at any time?  You may not even be notified of the change until your next visit.
  • Did you know that if you choose to get care out of network, you may not be covered for the treatment you elected to receive and the treatment could cost significantly more money?
  • Did you know that referrals in an HMO may not be needed for certain specialists?  Check with your insurance company for which specialties these are.

If you have questions about your coverage and need assistance understanding your policy, contact me, Your Obamacare Guy at (813) 391-3448 or  It is my pleasure to help people get the coverage they need to live the healthiest life possible!


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