| Network | Requires members to receive healthcare services exclusively from a network of providers and facilities, except in emergencies. | Offers a preferred network of providers but allows members to seek services from out-of-network providers at a higher cost. |
| Primary Care Physician (PCP) | Typically requires members to select a primary care physician (PCP) and obtain referrals for specialist visits within the network. | Does not always require a PCP or referrals for specialist visits, offering more flexibility in accessing specialists. |
| Out-of-Network Coverage | Generally does not provide coverage for services received from out-of-network providers, except in emergencies or with prior authorization. | Offers some degree of out-of-network coverage, with members typically responsible for higher deductibles, copayments, and coinsurance for such services. |
| Pre-Authorization | May require pre-authorization for specific services or procedures, both in-network and out-of-network, to determine medical necessity. | May require pre-authorization for specific services or procedures, particularly for out-of-network care, to ensure coverage. |
| Cost Sharing | Often features lower monthly premiums compared to PPO plans, making them cost-effective for individuals who stay within the network. | Typically has higher monthly premiums than HMO plans but offers more flexibility for members to use out-of-network providers if needed. |
| Deductibles and Copayments | May have lower deductibles and copayments for in-network services, making it more affordable for routine healthcare within the network. | Deductibles and copayments vary, with lower costs for in-network services and higher costs for out-of-network care. |
| Coverage Area | Usually operates within a specific geographic area or region, limiting access to network providers in that area. | Provides more flexibility for members to access healthcare services both locally and nationally through a broad network. |
| Referrals for Specialists | Typically requires referrals from a primary care physician to see specialists within the network. Out-of-network specialist visits are often not covered. | May not require referrals for specialists, allowing members to directly see specialists within or outside the network, although costs may vary. |
| Emergency Care | Covers emergency care both in-network and out-of-network, ensuring that members receive necessary care during emergencies. | Covers emergency care in-network and may provide some coverage for out-of-network emergency services. |
| Appeal Process | Provides an appeal process for disputing coverage denials or seeking exceptions for out-of-network care. | Offers an appeal process for disputing coverage denials or seeking exceptions for out-of-network care or medical necessity determinations. |
| Flexibility | Suited for individuals who are willing to select a PCP, obtain referrals, and prioritize lower premiums while using in-network providers. | Offers flexibility for individuals who want the option to see out-of-network providers on occasion while having access to a preferred network. |
