Provider Networks

In network refers to healthcare providers who have signed a contract with your health plan. Members pay less when using in-network healthcare providers.

Out of network refers to healthcare providers who have not signed a contract with the plan. Members pay more when using out-of-network healthcare providers. The exception is emergency care, which is covered at the in-network level no matter which emergency room you go to.

Different networks are created for distinct types of plans.

A broad network, such as a preferred provider organization (PPO), has the most providers available for members to choose from. Access to these networks is often associated with a higher premium cost for members.

A narrow network, such as an exclusive provider organization (EPO), has a limited number of providers. These networks often include specific lower-cost provider contracts associated with it, which allows for a lower premium cost for members.

For employer-based plans, the employer chooses which plans to make available to their employees. The plan chosen may have a more limited network available to keep health care premiums lower.

Networks are tied to a health plan and benefits. If you are covered under an employer-based plan, you may have a limited choice in what plans and networks might be available to you. When choosing a health plan, be sure to look closely at what providers are available to you in the plan and network. Changing to a different plan (if available) during the annual open enrollment period is the only opportunity to change your network.

Our goal is to ensure members have access to quality healthcare. As part of this work, Premera medical directors (physicians and clinicians from a broad spectrum of healthcare specialties) perform clinical reviews to:

• Make sure that coverage decisions are based on evidence-based medicine principles
• Align with medical policies
• Evaluate the medical necessity and safety of health care services

Physicians report that 15 to 30 percent of care is unnecessary,¹ so this review is our due diligence to ensure members have:

• Access to high-quality care
• The safest care possible
• The lowest out-of-pocket cost for needed care

Some health plans require members to designate a PCP. The PCP is your main contact for care—to provide treatment, coordinate with other members of your care team, and refer you to specialty care when needed. Even if it’s not a requirement of your health plan, it’s a good idea to have a PCP. People who have a regular primary care provider have greater trust in their provider, communicate better with their provider, and are more likely to receive appropriate care.²

Value-based care refers to a way health plans, such as Premera, pay healthcare providers. It ties payment to the provider’s improved results in the quality and cost of care they deliver to patients.

In the past, health plans paid providers for each appointment they held, each test they ordered, and so on. That payment model is called fee for service. While it is fair to pay people for work done, this model led to unnecessary treatment and, in the end, extra member expense.

Providers and health plans are moving toward value-based payment arrangements. In this model, health plans pay providers based on their ability to help you get healthier and/or stay healthy. It encourages providers to focus on delivering effective, efficient care. This is the core of the value-based care concept. It is a sustainable model for the future of healthcare.

A healthcare provider out of your plan network can set a higher cost for a service than those who are in your plan’s network. Charging this extra amount is called “balance billing".

You may be eligible for transition of care for a limited time if:

• You have been receiving treatment from a provider prior to enrolling on a Premera plan
• That provider is not contracted by Premera

Although services may be allowed, balance billing may still apply.

To find out if you’re eligible for transition of care, call the customer service number on the back of your member ID card.

You may be eligible for a benefit level exception. If so, you may be able to receive services at an out-of-network facility or from an out-of-network provider at the in-network cost.

Although services may be allowed, balance billing may still apply.

To find out if you’re eligible for a benefit level exception, call the customer service number on the back of your member ID card prior to receiving care.

You may be eligible for continuity of care for a limited time if:

• Your provider ends their contract with Premera,
• You are in active treatment for a covered service from a contracted provider,
• The treatment is medically necessary, and
• You and your provider agree it is desirable to maintain continuity of care.

Continuity of care typically allows up to 90 days of in-network rates after the provider’s contract ends. This is called the grace period. You will not be balance billed during this period.

To find out if you’re eligible for continuity of care, call the customer service number on the back of your member ID card.