When you’re shopping for health insurance, one of the factors that you’ll want to consider is the network. Knowing before you enroll what doctors
Network agreements between health insurance carriers and medical providers do change from time to time, so it’s important to check and make sure that a potential provider is in network before scheduling care. You can use the doctor search tool lower down on this page, or you can contact the doctor’s office directly.
Differentiating health plans: In-Network PPO, HMO or EPO
A preferred provider organization – PPO – is the most common network structure in the individual market in Colorado. With a PPO, there’s no need to select an official primary care physician. Most people have a primary doctor that they use for routine care, but it’s not necessary to get a referral from primary care doctor if you need to see a specialist. A PPO will have a network of doctors and hospitals that you can use. As long as you see providers who are part of that network, you’ll get the network negotiated pricing. You have the option to use a provider who is not in your plan’s network, but your out-of-pocket limits will generally be higher in this case (most PPPs have a separate out-of-network deductible and coinsurance in addition to the network limits on the plan). And non-network providers do not have to accept your plan’s payment as payment-in-full if it’s less than their regular rates – they can send you a bill for the difference, a practice known as balance billing.
A health maintenance organization – HMO – is a health plan in which the doctors, hospitals and the insurer are all working together to keep prices down and provide quality care to patients. It’s a more closely-knit business arrangement, and HMOs generally require members to select a primary care doctor who provides referrals to specialists as needed. In this way, the HMO keeps overutilization to a minimum. The network of providers is generally narrower than that of a PPO, and treatment from providers who are outside of the network is generally not covered at all unless it’s an emergency situation. In the individual market in Colorado, Kaiser Permanente is a well known HMO that has recently expanded from the Denver/Colorado Springs area into northern Colorado as well. They have the lowest prices of the plans in the Connect for Health Colorado Marketplace, but the trade off is that care is generally limited to the Kaiser Permanente facilities and a few select hospitals.
An exclusive provider organization – EPO – is sort of a hybrid of an HMO and a PPO. Members must generally use in-network providers in order to have services covered by the health plan (out-of-network emergency care is allowed), but a referral from a primary care doctor is not required, so members can opt to seek care from any network provider.
If you signed up with a PPO or HMO health insurance plan with and would like to find a doctor/specialist in your network or if you are thinking of signing up with a PPO or HMO plan and would like to see what networks your doctor belongs to, select your network from the menu below to do a search. The provider searches will look for any providers in the network nationwide, not just Colorado.
Tip: If you know which provider you’d like to use, call their office to confirm they take the insurance coverage as well. They may give you further insight about which health insurance companies they prefer. They may be planning to change whether they accept or don’t accept a certain carrier, etc.
However, remember that the contracts between the in-network PPO and HMO doctors/hospitals and health insurance providers are always in negotiation. If you see a doctor or hospital on the list of network providers for your health insurance plan, the agreement may have recently changed and the health insurance company may not have updated their website. Even if they’ve taken a certain insurance before, It’s always a good idea to call the doctor or hospital and ask them if they still accept your health insurance plan before each visit.
With the implementation of the health insurance marketplace exchange in 2014, large provider networks will be going away to be replaced by narrower, more cost efficient networks. Make sure to search again or re-check with your doctors and hospitals to ensure they’re a participating provider in your health insurance company network, even if you don’t switch plans on January 1, 2014. Not sure if you should switch? See what is changing, then get an estimate of what you’ll be paying, and we’ll be able to help you during open enrollment.