Tony Nefouse’s Complete Guide to Group Insurance: “Networks”

We come to the point where you are ready to start reviewing group insurance proposals. Before you start receiving insurance proposals information about your company should be taken into consideration. Employee location has a large impact on what type of plans a company should be entertain. Does the employer have employees in other states, does the employer plan on expanding into other states?

Most group health insurance plans will have some commercial system. The most common interface is the Preferred Provider Organization (PPO). PPO’s are considered a traditional network that most people are familiar have experience with. Anthem Blue Access, UnitedHealthcare has Choice Plus, Aetna Signature, Cigna Open Access, Sagamore Plus, PHCS, Encore would be PPO networks Indiana are familiar with. PPO offers large national systems with coverage for out-of-network providers.

Exclusive Provider Organization (EPO) is a type of network that is becoming more popular. The EPO usually is an extensive national network, but there is no coverage out of the system. Some people do not like the idea of not having out-of-network coverage. The EPO plan can cost less than a PPO and, in most cases, including most of the local medical providers. The gaps in the network usually come from costly medical facilities that choose not to join networks. A common out-of-network provider would be a drug rehabilitation center.

Health Maintenance Organization (HMO) provides a limited network of medical providers but could have a more integrated care model where all the medical providers are in communication with one another. In most HMO’s a member must choose a primary care doctor in advance. An HMO should have cost savings vs. the PPO & EPO because the network has more control over cost. Indiana does not have a lot of HMO’s to choose from, IU Health plans are one of the few carriers offering this type of program.

Point of Service (POS) is a hybrid of HMO & PPO plans where you must choose a primary care doctor but may have access to the PPO network. All care must go to the primary doctor. UnitedHealthcare has brought these plans back through its Navigate products.

Reference Based Pricing is a health plan that does use negotiated contracting with medical providers but instead confers the claim based on a multiplier of Medicare reimbursement rates. This type of arrangement is significantly cheaper because they remove multiple layers from the health care system. There is a significant risk with a doctor not accepting this type of agreement or balance billing by the provider to the patient.

Multi-State Employers:
If you have employees in multiple states, it’s important to look at a national network. Research the systems access for the out-of-state employees. Some insurance carriers will have a local PPO network with a different national network. Anthem is a perfect example of this with the Blue Access PPO network for Indiana and then the Blue Card network for the rest of the country. The HMO model may not be the best option for multi-state employers, and most HMO plans will have employee location requirements to be eligible for the program.

Dental Networks:
Dental networks are very similar to health plans where there are PPO & HMO models. Unlike health plans, PPO dental network may not provide access to most dentists. Dental providers have been reluctant to join dental systems because they do not want to discount their prices. Most dental plans will offer some level of coverage for out-of-network dentists. The DHMO may offer no coverage out of network but provide significant member savings in the system.

Vision Networks:
Vision networks seldom get the attention that health or the dental system will get. This could have to do with the cost of vision is relatively inexpensive vs. other insurance coverages. Vision plans also mimic health networks and most plans offer rich benefits in the network and some coverage for out-of-network.

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