Primary care network

What is a primary care network?

A primary care network is a roster of primary care physicians who provide health care to members of certain health insurance plans. Doctors in primary care networks often are referred to as general practitioners.

Deeper definition

Primary care physicians are doctors who practice general medicine. They’re who patients go to for annual checkups. Sometimes, nurse practitioners or physician assistants can be primary care providers. The primary care provider is a patient’s first stop for health care. Most primary care providers can treat conditions in their own offices; if not, they refer patients to specialists.

Many health insurance plans require their customers to stay within a certain network of care providers. When customers use providers outside their insurer’s network, they do not enjoy the same insurance coverage. Finding a doctor in the primary care network is most customers’ first order of business, as the primary care doctor is the overseer of their care.

When it comes to health insurance and network coverage, most plans fall into one of these tiers:

• Exclusive provider organization (EPO). The customer must stay within network for all doctor and hospital visits. Out-of-network visits are not covered at all, except for emergencies.
• Health maintenance organization (HMO). This plan covers only care by providers in the HMO’s network. Often these plans are location-specific, meaning the customer must either live or work within the coverage area.
• Point of service (POS). The customer agrees to see only providers who are within the plan’s care network and must obtain a referral from their primary care physician to see specialists within the network.
• Preferred provider organization (PPO). Customers pay less to see providers within the network, but they do have the option of visiting out-of-network providers. They’ll pay more to see providers outside their network, but less than what an EPO or HMO would cost.

Primary care network example

George has a POS health insurance plan through his employer. When he gets a cold or other routine illness, he sees a doctor he selected from the HMO’s primary care network. When George broke his leg, his primary care doctor referred him to an orthopedic physician who was in the PPO network. George’s health insurance carrier offers its members access to a database that contains the names and contact information for in-network doctors. George checks the database to see which doctors, hospitals and other health providers are in his network.

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