By Trish Pearson
Insure Your Future
Trish Pearson
Lately our office has received many questions regarding the advantages and disadvantages of choosing a health insurance plan with various types of networks.
The primary difference is flexibility versus cost. A health maintenance organization may offer lower premiums but requires the primary care physician to provide a referral for specialists and limits you to in-network providers for most care. Preferred provider organizations offer more flexibility with larger networks and the ability to see out-of-network providers and specialists without a referral, but the premium could be higher. If a provider belongs to an insurance company’s network, it means that they agree to accept a designated amount for services. This is a cost containment measure in return for steering patients to specific providers.
HMOs have a provider network that is either open access or gated access. In an open access plan, the patient does not need a referral to see a provider, but any provider must be in the network. A gated plan requires a referral from the primary care physician for a specialist. The patient must stay within the plan’s network of doctors and hospitals for care, except in emergencies.
These plans generally have lower premiums and lower maximum out-of-pocket costs. In Connecticut, most providers are in-network. However, it is important to check that all providers accept a plan before enrolling. Also, you must choose a primary care physician who coordinates your care and provides referrals to see specialists.
There is more flexibility in a PPO to use providers both in and out of network, although you might pay more for an out-of-network provider. These plans have more flexibility in that you do not need a referral to see a specialist, although you should still have a designated primary care provider who can suggest a specialist. Also, the copay for the primary care provider is lower than a specialist copay in most cases.
A point of service plan balances cost and flexibility. You can get out-of-network care and pay a higher copay. You may or may not need a referral from the primary care provider to see a specialist.
An exclusive provider network, on the other hand, only covers providers in its network, but the network is usually bigger than an HMO network. You may or may not need a referral from your primary care provider. Premiums may be higher than HMOs, but lower than PPOs.
Health insurers use a lot of acronyms related to their various plans. Many people are confused by the terminology. A Forbes report says that almost 56 percent of survey respondents were confused trying to understand health insurance. That is why it is helpful to seek the advice of an insurance broker. They are not paid by any single insurance
company and can unravel the complexities of the insurance web.
Your time is valuable, and a certified licensed broker will save you time and money, as well as helping you understand the reasons behind your insurance choice.
Trish Pearson is a licensed independent insurance agent and certified long term care specialist. Contact her at 203-640-5969 or trishpearson281@gmail.com.