Understanding health plan networks

What is a network?

A network is a group of healthcare providers, including doctors, hospitals and other medical facilities that have agreed to provide services at discounted rates to members of a specific health plan. Networks are designed to manage costs and ensure quality care.

Types of networks

• Health maintenance organization (HMO): an HMO plan requires you to use in-network providers and get referrals from a primary care physician (PCP) to see specialists.
• Preferred Provider Organization (PPO): a PPO plan offers more flexibility, allowing you to see both in-network and out-of-network providers, though at a higher cost for out-of-network care.
• Narrow network: Narrow Network plans offer lower premiums and provide access to quality care within a specific network of doctors and affiliated providers.

What is a provider?

A provider is an individual doctor, clinic, hospital or other health care entity that offers medical services. Providers can be either in-network or out-of-network:

• In-network providers: these providers have contracts with your insurance plan to offer services at reduced rates. Using in-network providers usually means lower out-of-pocket costs for you.
• Out-of-network providers: these providers do not have contracts with your insurance plan. Using out-of-network providers typically results in higher costs, and some services may not be covered at all.

How do I check if my current provider is in network?

It's important to check if your preferred doctors and hospitals are in-network to avoid higher out-of-pocket costs. If you have a MyPriority^® plan, there are a few ways to check if your doctor is in network:

1. Call your provider directly
2. Speak with a Priority Health enrollment specialist
3. Use Priority Health's Find a Doctor tool to check a specific network

What happens if I see an out-of-network provider?

Seeing an out-of-network provider can result in higher costs or no coverage at all, depending on your plan. It's essential to understand your plan's rules regarding out-of-network care.

Are there any restrictions on accessing specialists?

Some plans require a referral from your primary care physician to see a specialist. However, MyPriority plans do not require a referral for in-network specialists. Check with your primary care provider to see if a referral is needed.

What if I need emergency care?

Emergency care is typically covered regardless of whether the provider is in-network or out-of-network, but it's important to check your plan's specific rules. It's a good idea to know this information before you need emergency care.

What are the travel implications for my network?

If you travel frequently, consider a plan with a broad network or national coverage to ensure you can access care wherever you are.

Can I switch plans if my network needs change?

You can usually switch plans during the Open Enrollment Period (OEP) or if you qualify for a Special Enrollment Period (SEP) due to a qualifying life event (QLE).

Why is a large network important?

Having a large network, like Priority Health, has many benefits, including:

• Access to care: more options for doctors, specialists and hospitals
• Convenience: easier to find nearby in-network providers
• Continuity: likely includes your current healthcare providers
• Cost savings: lower costs with in-network providers
• Comprehensive coverage: access to a wide range of services
• Emergency situations: higher chance of nearby in-network emergency care
• Flexibility: more choices for switching doctors or seeking second opinions

Why choose Priority Health?

MyPriority members have access to a large network of high-quality primary care providers across Michigan. That – combined with our virtual urgent and virtual primary care options – means members can get care when and where they need it. Plus, you'll get high-quality care with award-winning customer service¹.

You get top value with a MyPriority health plan.