Provider Network Types

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.