Plan selection8 minute read
How to read a network before it reads you
Premium is printed in large type. Network adequacy is not printed at all. Here is the order to check it in.
Agent, Oakland · NPN 20553119
Premium is printed in large type. Deductible is printed in medium type. Network adequacy is not printed at all - it exists as a searchable directory maintained by the carrier, updated on the carrier's own schedule, and wrong often enough that experienced agents check it twice by two different methods. It is also the single decision most likely to produce a genuinely bad year.
Three shapes, and what each one is for
The letters describe how a plan handles two questions: whether you need a referral to see a specialist, and what happens if you see someone outside the network.
| Measure | HMO | EPO | PPO |
|---|---|---|---|
| Referral to a specialist | Required | Not required | Not required |
| Out-of-network coverage | Emergency only | Emergency only | Covered, higher share |
| Typical Silver premium | $412 | $448 | $566 |
| Annual premium difference | -$432 | Baseline | +$1,416 |
| Providers, metro county | 18,400 | 22,100 | 41,600 |
| Providers, rural county | 2,900 | 3,400 | 9,800 |
Illustrative figures for one rating area. The gap between metro and rural provider counts is the number that decides whether a narrow network is workable for a given household.
The EPO is the option nobody mentions. It has the referral freedom of a PPO and the in-network discipline of an HMO, and for a household that has no intention of leaving the network it is frequently the best value on the exchange. It exists because carriers wanted to sell the convenience of a PPO without funding the out-of-network liability, which happens to be exactly the trade most households would make if anyone offered it to them clearly.
The order to check it in
- Write down every provider the household will not give up. Not everyone they have ever seen - the ones that would actually cause a fight.
- Search each one in the carrier's own directory, by name and separately by practice address. They are indexed differently and one often finds what the other misses.
- Then telephone the practice and ask whether they take that specific plan. Not that carrier - carriers run several networks, and a practice can be in one and out of another.
- Ask about the coming plan year, not today. Contracts renegotiate annually, and a practice can be in network in December and out in January.
- Write down who told you, and when. It is the only leverage you will have if it is wrong.
A network is not a feature of the carrier. It is a feature of the plan, and two Silver plans from the same carrier can have entirely different physician lists.
Where narrow networks genuinely fail
Not usually at the primary care level. Primary care is dense almost everywhere and a narrow network will have someone taking new patients. The failures cluster in four places: paediatric subspecialties, oncology, behavioural health, and anything requiring a specific academic medical centre.1
They also fail at the edges of a rating area. A household living in a rural county with a metro hospital forty minutes away frequently finds that the cheap HMO's network stops at the county line, which is invisible until somebody needs the hospital.
The other half: the formulary
If anyone in the household takes a specialty drug, the formulary is the plan and everything else is decoration. Check the tier, check whether step therapy applies, check whether prior authorisation is required, and check whether the drug is on the list at all. A plan that covers every physician you want and excludes the one drug you need is not a good plan; it is an expensive one.
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