Understanding Your Plan's Network - American Exchange

Understanding Your Plan’s Network

Written By: Rachel Cullor

Date: June 10, 2015

One of the most essential things to understand about your marketplace health insurance plan is which network your policy is assigned to. A network is comprised of physicians, office, hospitals, labs, and pharmacies that have contracted with your health insurance carrier to accept the plan and offer certain rates for their members. Most insurance companies have several different networks that a plan can be a part of, with smaller networks costing less than the larger networks.

For example, Blue Cross Blue Shield of Tennessee offers three networks on the individual health market: the Essential (E) network, the Standard (S) network, and the Preferred (P) network. The smaller networks typically have a lower premium and usually make the most sense if you live in or near a major city that has several hospitals and doctors available. In rural areas, where doctors are few and far between and only one hospital is within 20 miles, a small network may not be the best option.

Some plans, such as HMOs, will only allow you to go to a doctor, hospital, or lab in network. If you go to a provider that is not part of your plans network, the health insurance company will not pay for any expenses that you incur, and you are left paying all of those related costs. Other health plans, such as the ones at BCBS of Tennessee, are PPOs. They allow you to go to anywhere that accepts the plan of your choosing, but you get significantly better benefits should you use someone that is in the network. Any expenses you accrue out of the network are not given any network discounts. For this reason, types of plans will usually have a deductible and maximum out of pocket for in network benefits, and a separate, much higher deductible and maximum out of pocket set up for out of network benefits.

How do I know what network my plan uses?

Most carriers will list the name of your network on your ID card. The name of your network will also be in the policy mailed to you once you make your first payment for the plan. But the easiest two ways to confirm your network would be to create a username and password for the health insurance company website if it is available, or by contacting your agent or the carrier directly to ask.

I know what network I have, but how do I locate providers that participate in it?

Most carriers have a provider search tool on their website. Once you locate it, you can search doctors and hospitals in your network by name, specialty, or even within a certain location. When the results of your search come up, you can usually see some basic contact information such as phone, address, and what specialty they are. Sometimes, you can even see if they are accepting new patients. We have also been able to find doctors that speak other languages when it is requested. The provider search tools are by far the best and easiest way to find a provider. However, it is always recommended to call the doctor’s office or hospital and verify that they are still participating in that network.

Networks are always changing. You could go to the same doctor for a yearly checkup for 5 years in row, and on your next visit, you could be told that the doctor is no longer accepting that plan or participating in your carrier’s network. You may have seen notices hanging in your doctor’s office that they will not be accepting certain carriers anymore. A lot of these changes or notices may happen while the provider works out a new contract with the carrier, but if the old contract expires and the new one has not been signed, that plan will not be accepted by the provider. To avoid any issues, the best practice is to always verify the doctor is still participating with your carrier’s network when making an appointment.