Teach the network.
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.
Four network skills every employee should have.
A few minutes on these prevents a large share of surprise bills.
How to look up a provider
Show employees where the carrier directory is and how to search by doctor, facility and plan, using the right plan name.
How to confirm before a planned procedure
Directories can be out of date. For planned care, call the provider and the carrier to confirm network status for the facility and the people involved.
What the plan type means
Whether a referral is needed, and whether any out-of-network benefit exists, depends on whether the plan is an HMO, PPO or EPO.
Where emergency care fits
Emergency care has its own federal protections. Employees should still know which nearby facilities are in network.
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
We bring the network question into the enrollment conversation.
Before employees choose, we help them check the doctors and hospitals they already use against each option, so network fit is part of the decision.
Related pages.
Why the Provider Network Is Part of the Plan
The same plan can cost very different amounts depending on which doctor or hospital an employee uses.
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.
What should employees see before open enrollment?
At minimum: the summary of benefits and coverage for each option, a plain definition of the key terms, a side-by-side of premium and likely cost, a way to check their doctors against the network, and a named person to ask.
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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