Health plans negotiate the price of medical services with certain doctors, hospitals, labs, pharmacies and other providers so the plan, and you, pay a lower cost. These providers are in your plan’s “network.” If you visit providers who are not in your network, you may have to pay more. Today, many insurers offer plans with “narrow” networks. These plans have a lower monthly premium, but as a trade-off, you have a limited choice of providers. Many plans sold in the health insurance marketplace have narrow networks, but some employers offer them, too. If you have one of these plans, it’s important to know which providers are in your network to avoid high out-of-pocket costs.
Are There Rules for Narrow Networks?
Plans with narrow networks, just like all health plans, must meet requirements set by state insurance and health laws, and other regulations. For instance, narrow network plans must have an “adequate” network of providers in each city or region they cover, and include certain types of providers, like primary care doctors and specialists. The definition of “adequate” is different from state to state, but it generally means a plan must have enough providers to deliver the services and coverage that it promises to its members. To see all the basic features of a health plan’s provider network, see Provider Networks.
How Do I Know If A Plan Has A Narrow Network?
A narrow network simply describes the number of providers in the health plan. Often, you may not even realize your plan uses one. To find out about the providers available to you, call your insurer, or check the insurer’s online provider directory. Use these Questions To Ask Your Insurance Plan as a guide. Since networks can change, you should also ask your doctor if he or she is in your plan before making an appointment. Hospitals and doctors in New York State are required to report the plan networks in which they participate. Learn more here.
The size of the provider network can also vary with different health plan types. Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs) are most likely to have narrow networks, but other plans may, too. You can read more about different types of plans.
Is a Narrow Network Health Plan Right for Me?
The best plan for you depends on your family’s specific health needs. Health plans with narrower networks typically have lower premiums. But, they also limit the number and type of providers available to you. If you are young and healthy, a plan with a narrow network may be a reasonable choice. The lower premiums may balance out the smaller network if you usually only visit your doctor for regular checkups, and don’t see a lot of specialists or require many medical tests.
If you or a family member needs care often, or has a chronic condition like diabetes or heart disease, a health plan with a narrow network may not work for you. You might need to see many different doctors and specialists, or get lab or imaging tests regularly. A narrow network could limit your options. And, if you leave the network for care, your out-of-pocket costs could add up quickly.
How Can I Manage My Costs in a Narrow Network?
If you visit a provider that is not in your plan’s network, you will likely have to pay more, for two reasons. First, that provider has not agreed to accept your plan’s rate, and can charge their usual full cost. Second, some plans with narrow networks do not cover any out-of-network costs, leaving you to pay the full price yourself. To learn more about in- and out-of-network care, read In-Network vs. Out-of-Network Care and Out-Network Docs at In-Network Hospitals.
If you find that you are in a narrow network plan, or choose to enroll in one, you can do some advance work to manage your costs. First, if you have a regular primary care physician, check that he or she is in your plan’s network. You should do the same for all your regular providers, including any specialists that you visit, labs where you have blood drawn, and the hospital network you prefer. Make sure that the doctors you might visit at that hospital are in the network, too.
Keep in mind that many insurers offer different plans with different networks. For instance, some insurers sell plans with large provider networks to employers, but sell narrow network plans in the health insurance marketplace. So, when you check who is in your network, make sure you are looking at the right network for your specific plan.
Your Action Plan – Find a Plan with a Network that Fits Your Needs
o Is this a narrow network plan?
o Are your doctors in the network, including specialists?
o What hospitals are your doctors affiliated with?
Are they in the network, too?
o How many network providers are close to where
you live and work?
Remember, New York State requires doctors and hospitals to provide information about the networks in which they participate.
And most importantly – speak up and ask questions. You are your own best advocate!