What Are Provider Networks and How Do They Compare?
Explanations to help you understand networks before choosing one over another
Reviewed by: Shikita Nunnery, Licensed Insurance Agent. Written by: Bryan Strickland.
Key Takeaways
A network can be made up of doctors, hospitals and other health care providers and facilities.
Medicare AdvantageMedicare Advantage (Medicare Part C) is health insurance for Americans aged 65 and older that blends Medicare benefits with private health insurance. This typically includes a bundle of Original Medicare (Parts A and B) and Medicare Prescription Drug Plan (Part D). has a provider network that must be used with Part AMedicare Part A, also called "hospital insurance," covers the care you receive while admitted to the hospital, skilled nursing facility or other inpatient services. Medicare Part A is part of Original Medicare. and Part BMedicare Part B is the portion of Medicare that covers your medical expenses. Sometimes called "medical insurance," Part B helps pay for the Medicare-approved services you receive..
Networks help to control costs for beneficiaries and the insurance companies.
When you’re choosing a provider network, it’s helpful to make a list of your healthcare “musts” and “wants” when comparing.
What’s the Plan?
It’s not easy to make sense of healthcare. When you start researching health insurance networks, there are few things to know. Let’s start with understanding the acronyms you’re bound to come across: HMO, PPO, and POS.
You’ve decided to enroll in a Medicare Advantage plan.
Now you have another decision to make: Which Medicare Advantage plan is right for you?
While Original Medicare allows you to see any provider that accepts Medicare, Medicare Advantage plans feature a network of providers.
- Generally speaking, the more willing you are to deal with regulations and restrictions related to navigating your network of providers, the more money you can save.
- But for others, the ability to see out-of-network doctors or to see a specialist without a referral is worth its weight in gold.
Those differing priorities are addressed in three types of Medicare Advantage plans: the HMO, the PPO and the POS. Here is a quick summary and a table to explain HMO and PPO and what’s covered.
HMO: In HMO Plans, you generally must get your care and services from providers in the plan’s network, except:
- Emergency care
- Out-of-area urgent care
- Out-of-area dialysis
PPO: In most cases, you can get your health care from any doctor, other health care provider, or hospital in PPO Plans. PPO Plans have network doctors, other health care providers, and hospitals.
Each plan gives you the choice to go to doctors, specialists, or hospitals that aren’t on the plan’s list, but it will usually cost less if you get your care from a network provider.
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Health Maintenance Organization (HMO) | Preferred Provider Organization (PPO) | Point of Service (POS) |
Overview An HMO is a tight network of quality health care providers whose services you may use with your health insurance plan. | A PPO plan gives you permission to visit any health provider you choose (including specialists), in or out of the network, without a referral. | A POS plan combines elements of HMOs and PPOs. They offer both In and Out-of-Network benefits, but require a primary care referral for specialized care. |
Coverage In-Network only | In-Network and Out-of-Network coverage | In-Network and Out-of-Network coverage |
Do you need a Primary Care Physician (PCP)? Yes, a PCP is required and acts as the gatekeeper for all specialist care. | No | Yes |
Referrals Yes, you will need referrals from your PCP for all specialized care | Referrals are not needed for specialized care | Yes |
Cost Lower | Higher | Middle |
Preventive Services In-Network preventive services are covered at 100%. | In-Network preventive services are covered at 100%. | In-Network preventive services are covered at 100%. |
Emergency Services Emergency Services are covered, regardless if obtained In or Out-of-Network. | Emergency Services are covered, regardless if obtained In or Out-of-Network. | Emergency Services are covered, regardless if obtained In or Out-of-Network. |
Health Maintenance Organization (HMO) | ||
Overview | An HMO is a tight network of quality health care providers whose services you may use with your health insurance plan. | |
Coverage | In-Network only | |
Do you need a Primary Care Physician (PCP)? | Yes, a PCP is required and acts as the gatekeeper for all specialist care. | |
Referrals | Yes, you will need referrals from your PCP for all specialized care | |
Cost | Lower | |
Preventive Services | In-Network preventive services are covered at 100%. | |
Emergency Services | Emergency Services are covered, regardless if obtained In or Out-of-Network. | |
Preferred Provider Organization (PPO) | ||
Overview | A PPO plan gives you permission to visit any health provider you choose (including specialists), in or out of the network, without a referral. | |
Coverage | In-Network and Out-of-Network coverage | |
Do you need a Primary Care Physician (PCP)? | No | |
Referrals | Referrals are not needed for specialized care | |
Cost | Higher | |
Preventive Services | In-Network preventive services are covered at 100%. | |
Emergency Services | Emergency Services are covered, regardless if obtained In or Out-of-Network. | |
Point of Service (POS) | ||
Overview | A POS plan combines elements of HMOs and PPOs. They offer both In and Out-of-Network benefits, but require a primary care referral for specialized care. | |
Coverage | In-Network and Out-of-Network coverage | |
Do you need a Primary Care Physician (PCP)? | Yes | |
Referrals | Yes | |
Cost | Middle | |
Preventive Services | In-Network preventive services are covered at 100%. | |
Emergency Services | Emergency Services are covered, regardless if obtained In or Out-of-Network. |