The most common regret we hear is finding out after enrolling that a doctor isn't in the plan's network. It's easy to check ahead of time. It takes about 15 minutes and can save you a lot of money.
Step 1: Make your list
Write down everyone you want to keep or need access to:
- Your primary care doctor and any specialists
- The hospital you'd want to go to in an emergency
- Your pharmacy
- Labs, imaging centers, and urgent care you actually use
Step 2: Use the plan's own directory
Search the provider directory for the specific plan you're considering, not just the insurance company's general site. A carrier can have several networks, and a doctor that's in one may not be in another. The plan name and network name are usually listed on the plan details page.
Step 3: Call the doctor's office
Directories go out of date. Call the office and ask: "Are you in-network with [plan name] on the [network name] network?" Give them the exact plan name, because "we take Aetna" or "we take Cigna" doesn't tell you whether they take the plan you're looking at. Ask the same about any specialist you've been referred to.
Step 4: Check the hospital and the doctors who work there
A hospital can be in-network while a specific doctor or group working there isn't. In South Florida, people often want one of the larger systems, for example Memorial Healthcare System, Broward Health, Cleveland Clinic Florida, Baptist Health South Florida, or Jackson Health System. Whether each one is in a given plan's network varies by plan, so check the plan, not the hospital's name.
Step 5: Look up your prescriptions
Plans publish a drug list, called a formulary, showing which medications are covered and at what tier. A medication in a higher tier costs more. If you take something regularly, check that it's covered and what you'd pay.
PPO, HMO and EPO: why it matters
- PPO. You can usually see out-of-network doctors, though you'll pay more. You typically don't need a referral to see a specialist.
- HMO. You stay in the network, usually choose a primary care doctor, and need referrals for specialists. Out-of-network care is often not covered except in emergencies.
- EPO. Like an HMO for network rules, but often without referrals.
If keeping your doctors matters a lot, a PPO gives you the most room, usually at a higher premium.
Write it down
Note the date, the person you spoke to, and what they said. If a bill later turns out to be out-of-network, that record helps when you dispute it. And if a doctor you need isn't in the plan, it's much easier to switch plans during enrollment than after.
This article is general information, not a guarantee of coverage or pricing. Plan availability, benefits, and eligibility vary by state and individual. Some private plans are medically underwritten and do not include all ACA essential health benefits.