2016 Open Enrollment FAQs about Networks and Providers
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- What are the differences between the networks that are available?
- PPO – Can receive care from any doctor you choose, no referral for specialty care, may use out-of-network doctors – but may have to pay addition fees. PPO plans typically have higher monthly premium.
- POS – Very similar to a PPO. The biggest difference is the contract between the insurance carrier and healthcare providers.
- HMO – Must pre-select an approved Primary Care Physician, referrals are needed and for most plans, there are no out of network benefits except for qualifying emergencies. HMO plans typically have lower monthly premiums.
- EPO – Hybrid network that has limitations that vary based on the carrier. In some instances, you would need to get referrals and may not have coverage for out-of-network. These plans typically have a lower monthly premium.
Please note: For all of the networks, it is best to review the Summary of Benefits (also known as the SBC; available under all plans when shopping in the exchange) to understand limitations before choosing your plan.
- Why are there fewer Individual PPO plans being offered in Texas?
Many carriers have decided to no longer offer Individual PPO plans.
- What are my options if no Individual PPO is being offered in my rating area?
- Look into alternative networks that are similar to a PPO plan.
- Firms can look into an employer-sponsored group health plan option that may have PPO options available. From now until December 15, 2015, certain participation and contribution rules have been waived.
- How do I find out if my doctor is in-network?
Once you have started shopping in the Exchange, you will see a bolded blue link that says “Find a Doctor or Hospital” below each plan you are viewing. Click on the link under the plan you are interested in and follow the instructions to confirm that your physician (enter the last name only) is in the network you are considering.