If you only check one thing before choosing a plan, check the network. It determines which doctors you can see, what you pay to see them, and what happens when you need someone the plan has not contracted with.
The two shapes
HMO. A closed network. Care is generally only covered in-network, except in an emergency. You usually name a primary care doctor, and specialist care usually needs a referral from them.
PPO. An open-ish network. In-network care costs less; out-of-network care is generally still covered, at a higher share to you. Referrals are usually not required.
There are variants — EPO, POS and others — that sit between. The two questions that actually separate them are always the same: is out-of-network covered at all, and do I need a referral.
Why an HMO is not automatically worse
HMOs usually cost less, and for someone whose doctors are all local and settled, the closed network costs nothing in practice. The trade only bites if you need someone outside it.
A PPO buys flexibility. Whether that flexibility is worth the difference depends entirely on whether you are going to use it.
The check that people skip
Provider directories are frequently out of date. Practices leave networks mid-year. A doctor can be in-network at one location and not another, or listed under a group that is contracted while they personally are not.
So the reliable check is a telephone call to the practice asking a specific question:
Are you contracted with this plan, under this exact plan name, for the coming plan year?
Take the name of whoever answers. Do this for every doctor you intend to keep, before you enroll — not after.
Referrals are an administrative fact, not a formality
On plans that require them, a specialist visit without a referral in place can be denied. The referral has to exist, be current, and be for the right specialty.
This is not usually a problem when everything is planned. It becomes one when care is urgent-but-not-emergency, or when a specialist wants to hand you to another specialist mid-course.
If you are managing an ongoing condition with several specialists involved, that is a real argument for the more open network even at a higher monthly cost.
Prior authorization
Separate from referrals: some services need the plan’s approval before they are provided, regardless of network shape.
Ask two things about any plan you are seriously considering: which common services require it, and what the typical turnaround is. A plan with a slow authorization process is a plan that will be frustrating in exactly the month you most need it not to be.
Emergencies
Emergency care is generally covered regardless of network. That is the one reliable exception, and it is worth knowing so nobody delays going to hospital while trying to work out whether it is in-network.
What happens after stabilization — a transfer, a follow-up, a stay — is where network rules resume applying.
The order to make the decision in
- List the doctors and facilities you will not give up.
- List your prescriptions with doses.
- Find the plans whose networks and formularies cover both.
- Then compare cost among what is left.
Doing it in the other order — cheapest first, check later — is how people end up switching again a year later, sometimes having lost a doctor in the process.
Being in-network is not one thing
Networks have tiers inside them. A plan can contract with two hospitals and still pay a much larger share at one than the other, and the cheaper tier is not always the nearer one. Drug networks work the same way: a pharmacy can be in-network and still not be preferred, which changes what you pay at the counter for exactly the same prescription.
None of this appears in the sentence “your doctor is in-network.” When you ring the practice, the useful follow-up is which tier they sit in, and whether that has changed for the coming plan year.
The doctor is not the only contract
People check the doctor and stop. A single procedure can involve a surgeon, a hospital, an anaesthetist, a pathology lab and an imaging center — and each of those has its own contract with your plan. The surgeon being in-network says nothing about the anaesthetist who happens to be on shift.
Federal surprise-billing protections have narrowed this considerably. They cover emergency care, and they cover out-of-network providers working at in-network facilities for most services. They do not cover everything — ground ambulance is a well-known gap in most states, and care you knowingly choose out-of-network is not a surprise bill at all.
Before anything scheduled, ask the facility which of the providers involved are contracted with your plan, and ask it of the facility rather than only the surgeon’s office.
What happens if your doctor leaves mid-year
Contracts end. When a practice leaves your plan partway through the year, you are generally not free to switch plans on the spot — a provider leaving the network is usually not, by itself, a Special Enrollment Period.
What you often do get is continuity of care: a defined period during which the plan keeps covering that provider at in-network terms while you transition, particularly if you are pregnant, mid-course in a treatment, or managing a serious condition. It is not automatic. You have to ask for it, in writing, and quickly.
If it happens, ring us the same week rather than waiting for the annual window. The options narrow with time.
Questions worth asking before you enroll
Ask these of the plan, and write down the answers with the date and the name of whoever gave them:
- Is every doctor on my list contracted for the coming plan year, under this exact plan name?
- Which hospital would I be admitted to, and is it in the preferred tier?
- Is my pharmacy preferred, or merely in-network?
- Do any of my current treatments require prior authorization, and what is the typical turnaround?
- If a provider leaves the network mid-year, what continuity of care does this plan offer?
An agent who cannot answer these, or who waves them off as detail, is telling you something useful about how the rest of the year will go.
We will run steps one to three with you for the plans we can offer. For everything available where you live, including plans we are not appointed with, the Medicare Plan Finder and HealthCare.gov are free and show the whole market.
Where to check this independently
Nothing on this page is advice about your situation, and none of it replaces the free sources. The Medicare Plan Finder, 1-800-MEDICARE, your SHIP counselor and HealthCare.gov are free, independent, and show plans we cannot sell.
Healthbase is a licensed insurance agency, not a government agency and not connected with Medicare or any federal or state program.
