Health plans with broad provider (PPO) networks cost about 12-15% more than those with limited (HMO) networks.
Mary is a young (34) Mom and entrepreneur. For herself and her four employees, she bought a small group health plan, choosing a lower cost HMO with comprehensive coverage, but only from two local health systems.
Despite her age, Mary was just diagnosed with a rare form of cancer. Like anyone in this situation, she’s researching options and thinks it may be necessary to go out of state for treatment. She asked if this would require pre-authorization.
Yes, but . . . . .
It is generally the provider’s responsibility to pre-authorize treatment. If the HMO’s local health system has limited or no experience with her specific cancer, she could be referred out of network.
Mary’s call should be to her insurer’s Nurseline asking to be assigned to an Oncology Case Manager, who will help her understand and navigate any treatment plans proposed. There is an all too common perception that profits, not patient advocacy, are health insurers’ top priority.
That’s quite simply wrong.
As a last resort, Mary could buy a new PPO group plan on the first of May, or any month!
