Selecting a Primary Care Doctor

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In the new world of health care reform, health insurance networks have become extremely important.

And in some cases, more complicated.

This year, when most Americans were required to buy health insurance through the government marketplace, the rules changed for some who were used to doctors they had long used.

Some insurance carriers began only offering HMO plans, which have a smaller more limited network of providers, as opposed to PPO plans, which offer a more expansive selection.

Bottom line: You may no longer be able to go to your regular doctor because of the changing insurance plans.

HMO stands for health-maintenance organization. These plans used to require you to select a primary care provider, or PCP, and have referrals to see other providers in the network. But most today have made them open access plans. It’s taken a lot of the negative connotation away from HMOs, but they do still have smaller, more limited networks.

A PPO, or preferred provider organization, is a health plan that contracts with a network of “preferred” providers. You don’t need to select a PCP, and unlike with an HMO, you don’t need a referral to see other providers in the network.

When someone is in a PPO, they’re hard-pressed to find someone not in the network. With an HMO, the providers are usually in a general geographic area, usually about a 20-30 mile radius.

When some carriers began to only offer HMOs, it became an issue for some people, especially those who live near state lines. Someone in far southern Virginia might have been traveling to North Carolina for care, while in southwestern Virginia, it was closer and easier to go to doctors and hospitals in Bristol or Kingsport, Tennessee.

Consumers are now faced with the decision about whether to stay within their network—or to find new doctors because their old ones aren’t in that network. In-network benefits generally have 80-20 percent coverage, while out-of-network means the consumer pays more, as much as 50 percent. So if you have an HMO and choose to go out-of-network for a certain doctor, or to have a procedure done at a certain hospital, you’re going to pay for it.

On top of that, there are different HMO networks. “Pathway X” networks (the X is short for exchange, meaning the plan was purchased through the health exchange) are those policies that receive a subsidy. Policies for those who didn’t qualify for a government subsidy fall under “pathway” networks.

So doctors might be in one pathway network, but not the other.

Consumers choosing individual health plans are having to make hard decisions—do they get a subsidized plan and pay less in premiums, but have less access to certain doctors and medical facilities? Or can they afford to pay more in premiums and get a PPO policy? HMOs generally run 10 to 15 percent less in premiums than PPOs do.

The decision can come down to how much a consumer wants to stick with a particular doctor, or medical facility. To help consumers figure out what plan covers what, the insurance carriers all have “find-a-doctor” searches on their websites that are changing constantly, with providers coming on and going off all the time.

At Experient Health, we encourage individuals to use those search tools. The choices are always changing, sometimes by the day.

In urban areas, consumers are likely going to have many options for doctors and medical facilities. It’s the more rural areas where decisions are having to be made, although there are ongoing talks with carriers about changing the rules for people who live near border states.

Whatever plan you choose, and whatever doctor you choose to see, it’s always wise to make a phone call ahead of time to be sure you’re covered. That part, at least, is still pretty simple.