The network is part of the plan.
The same plan can cost very different amounts depending on which doctor or hospital an employee uses. The network is not a footnote. It is half the benefit.
Four ways the network changes the bill.
Employees who compare only premium and deductible are missing the variable that moves cost the most.
In network and out of network are priced differently
In-network providers have agreed to the plan rates. Out-of-network care is often reimbursed at a lower level, or not at all on some plan types.
The same plan means different costs for different doctors
Two employees on the same plan can pay very different amounts for the same service depending on whether their provider is in network.
Plan type shapes how much choice there is
HMO, PPO and EPO plans treat networks and referrals differently. The plan type is part of what an employee is choosing.
Check the facility, not only the doctor
An in-network surgeon can operate at a hospital that is outside the network. Ask about the facility and the related providers before a planned procedure.
What the rules say.
The figures and requirements below come from the federal sources cited at the end of this section. General information, not legal advice.
Emergency care is protected
Under the federal No Surprises Act, emergency services cannot be billed to the patient at more than the in-network cost-sharing rate, including at out-of-network emergency rooms and most post-stabilization care.
Some out-of-network providers at in-network facilities are protected
Non-emergency care at an in-network hospital, hospital outpatient department or surgical center is covered by the same protection. A doctor office that is not a hospital outpatient department is not.
Ground ambulances are not covered
The federal protections reach air ambulances, but ground ambulances can still bill out-of-network rates unless state law says otherwise.
Signing a consent form can waive the protection
Some providers ask patients to sign a notice and consent form. Signing it gives up the surprise-billing protection, and patients can decline. Complaints go to the No Surprises Help Desk at 1-800-985-3059.
Sources: CMS: Know your rights with insurance
What Michigan asks of a network.
A network is part of the plan, and in Michigan insurers file their networks with the state. This is what that means for an employer checking one.
Insurers File Network Data With DIFS
Network adequacy filings include a Network ID, a service area and a Michigan Network Data listing. Every provider in the network must be listed.
DIFS Publishes Annual Guidance
DIFS posts its Michigan Network Adequacy Guidance each year. It is the document to read for how networks are reviewed.
Accreditation Does Not Replace the Filing
Accreditation by NCQA, URAC or AAAHC does not exempt an entity from network adequacy filings in Michigan.
Where to Ask Questions
DIFS answers general questions at 877-999-6442, Monday through Friday, 8 a.m. to 5 p.m., or at DIFSInfo@michigan.gov. Start with the carrier’s network ID and directory.
DIFS help line: 877-999-6442 · DIFS: network adequacy FAQ
We teach the network before the plan is picked, not after the first claim.
We show employees how to check their own doctors and hospitals against the network before enrollment closes, so the question that matters most is answered while there is still time to act on it.
Related pages.
Teaching Employees How Their Network Works
Employees need to know how to check whether a doctor or hospital is in network, and what happens if it is not, before they need care.
HMO vs PPO vs EPO
How the plan types treat networks, referrals and choice.
Why did we get a bill after a visit that only had a copay?
Because the copay usually covers the visit itself and not everything billed around it.
Avoiding Group Health Insurance Plan Confusion
The full guide to helping employees understand their group health plan.
Questions that come up next.
Short answers to the questions employees ask after this one. Each links to its own page.
Who should an employee call about a claim they do not understand?
Start with the member services number on the back of the insurance card, which can explain how the claim was processed. If it still does not make sense, the employee should call their benefits contact, who can look at the plan documents and the explanation of benefits.
Why do employees pick a plan that does not fit them?
Usually because the choice is made fast, from a table of numbers, with the premium doing most of the persuading. Few employees see a worked example of what the plan costs in a hard year, or check whether their doctors are in the network.
What is the difference between a deductible and an out-of-pocket maximum?
The deductible is what an employee pays for covered care before the plan starts sharing the cost. The out-of-pocket maximum is the most the employee pays in a year for covered in-network care. One is where sharing begins, the other is where it ends.
Ready? Send us your renewal, or talk it through with someone first. No cost, no obligation.
General information about group health plan terms, not legal or tax advice. Plan-specific questions belong with the plan documents and the carrier.
Send us your renewal.
We’ll tell you whether it looks competitive, where we see opportunity, and the five questions we’d put to your carrier. No cost, and no obligation to move anything.
The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents, two more if your group is 50 or more. Nothing else; every extra one is a reason to postpone.
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