Provider Network

The contracts behind your coverage

When an insurer builds a plan, it signs agreements with healthcare providers who accept set rates for their services. Those providers make up the plan's network. Staying in network means:

• You pay the plan's in-network cost sharing.
• Your costs count toward your in-network out-of-pocket maximum.
• Providers cannot bill you above the negotiated rate for covered services.

Leaving the network can mean higher costs or no coverage at all, depending on the plan type.

Broad vs narrow networks

Networks vary widely, even between plans from the same insurer:

• Broad networks include most doctors and hospitals in an area, sometimes nationwide.
• Narrow networks limit you to a smaller set of providers, often tied to one or two hospital systems, in exchange for lower premiums.
• Tiered networks cover all providers in the network but charge less for preferred ones.

Example

The Johnson family moved to Tampa from another state in the spring. They pick the cheapest Marketplace plan available. Months later, their son needs a pediatric specialist, and they learn the closest in-network specialist is over an hour away because the plan uses a narrow network built around one hospital system. A slightly more expensive plan with a broader network would have included the children's hospital ten minutes from their home.

The lesson: check the network for the care you are most likely to need, not just your primary doctor.

How to check a network

• Use the insurer's provider directory for the exact plan name, not just the insurer.
• Call your doctor's office and ask whether they accept that specific plan for the coming year.
• Check your preferred hospital, any specialists, and your pharmacy.
• Look at labs and imaging centers, since those are easy to overlook.

Directories are not always current, so a phone call is worth the time.

Marketplace vs private plans

Marketplace plans in many states, including Florida, lean toward HMO and EPO designs with regional networks, which helps keep premiums down. Private plans outside the Marketplace often use national PPO networks, which can be useful for people who travel, split time between states or have family members living elsewhere. Network breadth is one of the main reasons people with income above the subsidy line compare private plans.

Networks change

Providers join and leave networks every year. A doctor who was in network last year might not be this year. Review your network during open enrollment and when you get your renewal notice.

Our guides on moving to Florida and health insurance and the annual health insurance plan review cover how to protect yourself. To check networks for your doctors across several plans, request a quote.