The quality and extent of a health plan’s provider and health care facility network can be a central factor in deciding whether to stay with a health plan or to find a new one. It’s important to have access to the care you need from providers you want while still protecting your budget.
During Open Enrollment, we recommend you take the time to assess your health plan’s network. Does it still work for you? How does it compare to other plans’ networks? Answering these questions may take a little time and research but will give you confidence in your health plan decisions.
Let’s Start with Definitions
In health insurance language, a network is a collection of providers and health care facilities who contract with a health plan to provide services to members at a rate that is less than their usual fees.
When you get care from an in-network provider or use an in-network facility, you save money. Conversely, out-of-network providers and healthcare facilities are providers and facilities that do not contract with your health plan. Generally, you pay more when you go out-of-network.
Bookmark this blog that defines common health insurance terms to help guide you as you assess and make your decisions this Open Enrollment.
Three Steps to Assessing a Network
Your comfort in seeking and receiving care is very important. Take time to make sure you’re getting the best care you can while still protecting your budget. Following the below three-step review will help you evaluate a plan’s network and if it can allow you to do just that.
1. Confirm Certifications and Quality Ratings
When it comes to entrusting your health with a provider, you can’t be too careful. Find out if your provider is a board-certified doctor at certificationmatters.org. A doctor that’s certified by the American Board of Medical Specialties (ABMS) has:
- Earned a degree from a qualified medical school.
- Had 3 to 7 years of accredited residency.
- A license from a state medical board.
- Passed one or more exams administered by a member of the ABMS.
- Continuing education requirements.
Next, look into your provider’s quality ratings. The National Committee for Quality Assurance (NCQA), for example, measures provider and health plan quality and recognizes high-quality through certain programs. Their goal is to help consumers — like you — find the best care and coverage available. You can search to see if your providers have received NCQA recognition. Do you need to see a specialist? The American Board of Medical Specialists certifies many different specialties and subspecialities that you can verify online.
2. Word of Mouth Reviews
Standardized quality measurements give you empirical data to make decisions on. However, there’s a lot to be said for other patient reviews. Getting opinions from others on a provider can give you an insight on the more intangible qualities of a physician, like bed-side manner, the office’s customer service, appointment availability, and more. Start by asking your friends, family, and coworkers for recommendations. Then, take the search online to find other patient reviews at:
- Healthgrades
- RateMDs.com
- Vitals.com
- And, for good measure, Yelp.com
3. Out-of-Network Benefits
It may seem counterintuitive but evaluating your plan’s network includes considering the out-of-network benefits. There may be times when you need to get care from an out-of-network provider or facility. To find out if someone is out-of-network, you can call their office to ask what health plans are accepted or contact the VEBA Advocacy Team at 888-276-0250 for assistance.
You can still seek care out-of-network, but you may need to be prepared for the financial impact of that choice. For most plans, if you go out-of-network, you will likely pay more. Some plan types will not cover out-of-network care at all while some cover only a portion of the costs. Look in your Summary of Benefits and Coverage (SBC) to see what your current plan covers or in the SBC of other plans to compare this benefit.
Supporting You Now and Next Year
During Open Enrollment, take the time to evaluate your plan’s network and how it has worked for you in 2024. Determining the right network coverage is a balancing act of access to top quality and controlling costs. We’re here to help if you have questions. Call the VEBA Advocacy Team at 888-276-0250 or visit vebaonline.com/contact.
VEBA Resources
MyVEBA Portal: View your current benefits information quickly through the MyVEBA app or online portal. Download the app for Apple or Android, or visit the MyVEBA Portal for desktop access.
Benefit Contacts: For assistance with specific carrier benefits or issues, such as claims or coverage details, visit vebaonline.com/benefit-contacts to contact them directly.
Get Support: Before you make your choices during Open Enrollment, it’s helpful to talk through your health plan options with someone. The VEBA Advocacy Team is there for you during Open Enrollment and beyond. Call 888-276-0250 or visit vebaonline.com/contact for assistance. For urgent requests, use the “Urgent” box on the contact form.
