Navigating the Health Insurance Landscape by Robert Adziashvili - HTML preview

Navigating the Health Insurance Landscape

4. ACA: The impact of network restrictions: PPO, POS, HMO

The Affo rdabl e Care Ac t ( ACA) has had a si gn i fi c an t i mpac t o n n et wo rk rest ri c t i o n s i n heal t hc are. Net wo rk rest ri c t i o n s refer t o t he gro up o f heal t hc are pro v i ders t hat are c o v ered by a part i c ul ar i n suran c e pl an . U n der t he ACA, i n suran c e c o mpan i es are requi red t o o ffer pl an s wi t h adequat e pro v i der n et wo rk s t o en sure t hat i n di v i dual s hav e ac c ess t o a wi de ran ge o f heal t hc are serv i c es. Thi s mean s t hat i n di v i dual s hav e mo re c ho i c es when i t c o mes t o sel ec t i n g t hei r heal t hc are pro v i ders.

O n e way t o n av i gat e t he n et wo rk rest ri c t i o n s i s by un derst an di n g di fferen t t ypes o f i n suran c e pl an s. O n e c o mmo n t ype i s a Preferred Pro v i der O rgan i z at i o n ( PPO ) . Wi t h a PPO , i n di v i dual s hav e t he freedo m t o c ho o se an y heal t hc are pro v i der, bo t h i n -n et wo rk an d o ut -o f-n et wo rk , wi t ho ut requi ri n g a referral . Ho wev er, usi n g i n -n et wo rk pro v i ders wi l l usual l y resul t i n l o wer o ut -o f-po c k et c o st s.

An o t her t ype o f pl an i s a Po i n t o f S erv i c e ( PO S ) pl an . PO S pl an s usual l y requi re i n di v i dual s t o sel ec t a pri mary c are physi c i an ( PCP) who serv es as a gat eway t o o t her spec i al i st s. In -n et wo rk serv i c es are t ypi c al l y c o v ered at a hi gher rat e, but i n di v i dual s may hav e t he o pt i o n t o rec ei v e c are fro m o ut -o f-n et wo rk pro v i ders by o bt ai n i n g a referral fro m t hei r PCP.