Health insurance can be tricky to navigate. In the U.S., managed care insurance plans require policyholders to get their care from a network of designated healthcare providers. If patients seek care outside the network, they must pay a higher percentage of the cost. The insurer may even refuse payment outright for services obtained out of network.10
Most managed care plans—such as health maintenance organizations (HMOs) and point-of-service plans (POS)—require patients to choose a primary care physician who oversees the patient’s care, makes recommendations about treatment, and provides referrals for medical specialists.11
Preferred provider organizations (PPOs), by contrast, don’t require referrals. However, they do set lower rates for using in-network practitioners and services.12
Insurance companies may deny coverage for certain services that were obtained without preauthorization. They may refuse payment for name-brand drugs if a generic version or comparable medication is available at a lower cost. Check an insurance company’s rules before you buy their insurance.
