Having trouble confirming your doctors are in-network, especially PAMF?

2014 has brought many changes to small group and individual health insurance plans.  Even Medicare is being impacted by the new health care law.  One major problem that comes up daily is determining if doctors and medical groups are in-network.

Small group plans are, for the most part, locked into their contracts until the renewal date in 2014.  If you are among the 80% of small businesses that early renewed, good for you!  Your employee benefit package will remain untouched and you do not have to worry about changing doctor networks until early fall.  However, businesses with between 2-50 employees and a Risk Adjustment Factor of 1.1 should consider moving to a new plan prior to their renewal.  A 1.1 RAF means you pay the highest rate possible in the pre-Obamacare market.  Just call for a quote but you could save hundreds per month!

Individuals and families are impacted immediately by the changes in doctor networks and Rx formulary lists.  Staying inside of your PPO or HMO network is of the utmost importance when utilizing your health insurance.  Certainly, plenty of us opt to go to out of network providers but be aware that that cost is an out of pocket expense.  Using out of network providers will result in higher cost and, with almost all plans, is subject to a separate out of network deductible with low reimbursement from your health insurance plan.

So, let’s assume that you stay in-network.  It should be such a simple thing, right?  Call your agent or go online to your insurance carrier website, find a list of doctors and make your appointment.  It used to be so easy.  However, with the new changes, many insurance carriers now have multiple PPO networks.  Beware if you are buying certain PPO plans that have traditionally worked with major carriers, like PAMF or UCSF.  Many new PPO contracts may not continue these relationships and you would not know about it until after the fact, which would be an expensive lesson to learn!

Lesson: Do not make assumptions with your new insurance.  Check ahead on doctor networks and drug formulary lists.