Medical
Health Care Provider Networks
The networks available to you are determined on where you live. The insurance companies offering plans in Maine have the following network types:
- Preferred Provider Organization (PPO) - The insurer contracts with a network of hospitals and other medical providers (“preferred providers”) who agree to accept lower fees. You receive a higher level of benefits if you go to a preferred provider than if you go to an out-of-network provider.*
- Health Maintenance Organization (HMO) - You must choose a primary care provider (the provider you would see for your annual physical) from a list of participating providers. For any non-emergency hospital or specialty care you must get a referral from your primary care provider first. Typically, out-of-network providers are not covered.
- Point of Service (POS) - Has characteristics of both HMOs and PPOs. Like an HMO, you must choose a primary care provider (PCP) from a list of participating providers, and for any non-emergency hospital or specialty care you must get a referral from your PCP first. Like a PPO, you can see an out-of-network provider but you will pay more than you would to see an in-network provider.* Out-of-state providers may or may not be covered.
- Tiered Network - Under this type of plan, you will receive the highest level of benefits if you see providers in the preferred tier. You will still be able to access in-network providers in lower tiers, but your cost-sharing will be higher.
Not all types of networks are available in all areas of the state.
* Note: If you use an out-of-network provider, a provider in a lower tier, not only will your cost-share be higher, but you will have more than one out-of-pocket maximum amount to meet for the year, which can add significant expense.