You have choices when you shop for health insurance. If you’re buying from your state’s Marketplace or from an insurance broker, you’ll choose from health plans organized by the level of benefits they offer: bronze, silver, gold, and platinum. Bronze plans have the least coverage, and platinum plans have the most. If you are under 30, you may also be able to buy a high-deductible, catastrophic plan.
How are the plans different? Each one pays a set share of costs for the average enrolled person. The details can vary across plans. In addition, deductibles — the amount you pay before your plan picks up 100% of your health care costs — vary according to plan, generally with the least expensive carrying the highest deductible.
You will also see insurance brands associated with the care levels. Some large national brands include Aetna, Blue Cross Blue Shield, Cigna, Humana, Kaiser, and United.
Each insurance brand may offer one or more of these four common types of plans:
- Health maintenance organizations (HMOs)
- Preferred provider organizations (PPOs)
- Exclusive provider organizations (EPOs)
- Point-of-service (POS) plans
- High-deductible health plans (HDHPs), which may be linked to health savings accounts (HSAs)
Take a minute to learn how these plans differ. Being familiar with the plan types can help you pick one to fit your budget and meet your health care needs. To learn the specifics about a brand’s particular health plan, look at its summary of benefits.
Health Maintenance Organization (HMO)
An HMO delivers all health services through a network of healthcare providers and facilities. With an HMO, you may have:
- The least freedom to choose your health care providers
- The least amount of paperwork compared to other plans
- A primary care doctor to manage your care and refer you to specialists when you need one so the care is covered by the health plan; most HMOs will require a referral before you can see a specialist.
What doctors you can see. Any in your HMO’s network. If you see a doctor who is not in the network, you’ll may have to pay the full bill yourself. Emergency services at an out-of-network hospital must be covered at in-network rates, but non-participating doctors who treat you in the hospital can bill you.
Preferred Provider Organization (PPO)
With a PPO, you may have:
- A moderate amount of freedom to choose your health care providers — more than an HMO; you do not have to get a referral from a primary care doctor to see a specialist.
- Higher out-of-pocket costs if you see out-of-network doctors vs. in-network providers
- More paperwork than with other plans if you see out-of-network providers
What doctors you can see. Any in the PPO’s network; you can see out-of-network doctors, but you’ll pay more.
What you pay:
- Premium: This is the cost you pay each month for insurance.
- Deductible: Some PPOs may have a deductible. You will likely have to pay a higher deductible if you see an out-of-network doctor.
- Copay or coinsurance: A copay is a flat fee, such as $15, that you pay when you get care. Coinsurance is when you pay a percent of the charges for care, for example 20%.
- Other costs: If your out-of-network doctor charges more than others in the area do, you may have to pay the balance after your insurance pays its share.
Paperwork involved. There’s little to no paperwork with a PPO if you see an in-network doctor. If you use an out-of-network provider, you’ll have to pay the provider. Then you have to file a claim to get the PPO plan to pay you back.
Exclusive Provider Organization (EPO)
With an EPO, you may have:
- A moderate amount of freedom to choose your health care providers — more than an HMO; you do not have to get a referral from a primary care doctor to see a specialist.
- No coverage for out-of-network providers; if you see a provider that is not in your plan’s network – other than in an emergency – you will have to pay the full cost yourself.
- Lower premium than a PPO offered by the same insurer
What doctors you can see. Any in the EPO’s network; there is no coverage for out-of-network providers.
- Premium: This is the cost you pay each month for insurance.
- Deductible: Some EPOs may have a deductible.
- Copay or coinsurance: A copay is a flat fee, such as $15, that you pay when you get care. Coinsurance is when you pay a percentage of the charges for care, for example 20%.
- Other costs: If you see an out-of-network provider you will have to pay the full bill.
Paperwork involved. There’s little to no paperwork with an EPO.
Point-of-Service Plan (POS)
A POS plan blends features of an HMO with a PPO. With POS plan, you may have:
- More freedom to choose your health care providers than you would in an HMO
- A moderate amount of paperwork if you see out-of-network providers
- A primary care doctor who coordinates your care and who refers you to specialists
What doctors you can see. You can see in-network providers your primary care doctor refers you to. You can see out-of-network doctors, but you’ll pay more.
What you pay:
- Premium: This is the cost you pay each month for insurance.
- Deductible: Your plan may require you to pay the amount of a deductible before it covers care beyond preventive services. You may pay a higher deductible if you see an out-of-network provider.
- Copays or coinsurance: You will pay either a copay, such as $15, when you get care or coinsurance, which is a percent of the charges for care. Copayments and coinsurance are higher when you use an out-of-network doctor.
Paperwork involved. If you go out-of-network, you have to pay your medical bill. Then you submit a claim to your POS plan to pay you back.
Catastrophic Plan
If you are under the age of 30 you can purchase a catastrophic health plan. With a catastrophic health plan you may have:
- Lower premium
- 3 primary care visits before the deductible applies
- Free preventive care, even if you haven’t met the deductible
You can set up a Health Savings Account to help pay for your costs. The maximum you can contribute to an HSA in 2022 is $3,650 for individuals and $7,300 for families. You can contribute an additional $1,000 if you are 55 or older.
Paperwork involved. Keep all your receipts so you can withdraw money from your HSA and know when you’ve met your deductible.