We have had a few patients call to ask about guidance in choosing a health insurance plan. The Affordable Care Act requirements have many people considering their options. So it is a good time to talk about one of the confusing aspects of health insurance.
There are several different kinds of health insurance policies, but they break down into 3 basic groups: HMO plans, PPO only plans, and plans that offer broader coverage. HMO plans usually only cover care at the HMO’s own facilities and with their own providers. Some of these plans may have options for going outside the HMO, usually with restrictions such as a requirement to get a referral and pre-approval. PPO (Preferred Provider Organization) plans are similar to an HMO but different providers and facilities are grouped into a network by the insurance company. Many of these HMO and PPO plans only cover care within the HMO or network. Broader, more traditional plans may have networks, but they also provide some level of insurance coverage for providers that are outside the network.
We strongly recommend policies that have out-of-network coverage. The reasons are simple. Many of the limited provider groups, whether HMOs or PPO networks may not have the ability to provide what you need, when you need it. Small networks mean providers may not have open appointments in a reasonable timeframe, or providers with the skills to treat your problem. We recently had a patient who found that although her federal employee “basic” plan said it covered acupuncture, there weren’t any providers in the network who were licensed to provide acupuncture.
In fact, some of the plans offered have been rejected from the exchanges because state officials found that the networks were obviously too small to actually provide adequate care. Even “adequate” plans may not meet your needs, especially if you need healthcare while away from home. Another problem is that doctors and hospitals can, and do, drop out of networks. The doctor you see now may be in the network today, but could drop it at any time.
Having out-of-network coverage is essential to get coverage when you need it, from the providers and facilities that you need.