Outside of employer-offered health insurance plans, there is a variety of options for families and individual residents to choose from.
These plans can be found on residents’ state health insurance marketplace websites. For each plan, there are different payment structures, coverage levels and health care providers.
Selecting the right health insurance plan involves researching the numerous available options and verifying what each cover.
By reading the sections below, you can learn about the six different types of plans that you are likely to encounter in your search.
These plans include Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), Exclusive Provider Organizations (EPO), Point-of-Service Plans (POS), Fee-for-Service (FFS) plans and High-Deductible Health Plans (HSA).
Learn About the Levels of Coverage in the Health Insurance Marketplace
Health insurance plans vary significantly so it can be hard to know how to choose the right plan.
However, residents can determine their eligibility for each through their state health insurance marketplace.
Plans are often categorized into levels. These include catastrophic, bronze, silver, gold and platinum levels.
The primary difference between the levels of coverage is the costs.
Generally, plans with high monthly premiums have lower deductibles while cheaper plans have higher deductibles.
Below are the coverage levels that residents can choose from:
- Catastrophic Health Insurance Plans – Cover approximately less than 60 percent of the total cost of care on top of the full coverage for the first three primary care visits and other preventive care options. Usually, residents must be at least 30 years of age or younger to enroll in these plans.
- Bronze-level coverage – Covers approximately 60 percent of medical costs on average while you pay 40 percent.
- Silver-level coverage – Covers approximately 70 percent of medical costs enrollees pay 30 percent.
- Gold-level coverage – Covers approximately 80 percent of medical costs while members pay 20 percent.
- Platinum-level coverage – Covers approximately 90 percent of medical costs while beneficiaries pay 10 percent.
Learn About Options in the State Health Insurance Marketplace
There is a handful of large health insurance providers in the United States who offer coverage options in most states.
These companies include Blue Cross, United, Kaiser, Cigna, Aetna and Humana.
In addition, each offers different programs like HMO, PPO, POS, FFS, EPO and HDHP. Continue reading about health insurance plan type.
About Health Maintenance Organizations
Health Maintenance Organizations (HMOs) allow enrollees to obtain medical coverage within the provider’s established network of medical professionals and facilities.
They offer the least freedom to beneficiaries in choosing their providers and require a referral from a primary care physician to visit a specialist.
However, this is one of the most affordable health insurance options for residents.
With an HMO plan, beneficiaries who seek non-emergency services outside of the network will be required to pay all expenses on their own.
In addition, costs for HMOs can vary greatly but monthly premiums are generally low compared to other plans.
However, deductibles and the out-of-pocket maximum must be met before insurance must be meet 100 percent before the provider will begin contributing to costs.
About Preferred Provider Organizations
Preferred Provider Organizations, or PPOs, give beneficiaries more freedom in selecting their providers than HMOs.
Residents with PPO plans are not required to obtain a referral before visiting a specialist.
Furthermore, they are often covered, at least partially, when visiting an out-of-network physician.
That is because Preferred Provider Organizations allocate a certain percentage of their costs to out-of-network medical professionals.
Because enrollees are permitted to visit doctors outside of their network, they are often subject to paperwork that HMO members are not required to fill out.
They will usually be required to file a claim with their insurance provider and pay the medical costs upfront.
Then, they will have to wait for reimbursement from their insurance company.
About Exclusive Provider Organizations
Exclusive Provider Organizations (EPOs) are similar to PPOs in that they allow enrollees to choose their medical providers and see specialists without a referral.
However, these plans do not cover out-of-network visits that are not emergencies.
Companies that offer PPOs usually also offer the EPO option. Exclusive Provider Organization plans often have cheaper premium rates than PPOs due to the decreased coverage for non-network providers.
Residents often choose this plan so they can see the specialists that they need to without having to schedule more appointments with their primary care doctor.
About Point of Service Plans
Point-of-Service (POS) plans allow enrollees to visit providers who are both in and out-of-network.
They offer more freedom of choice than HMOs but are cheaper than PPOs and EPOs.
Just as with PPOs, beneficiaries are required to pay more for out-of-network services than for in-network services.
Enrollees will have to complete little to no paperwork for in-network services.
About Fee for Service Plans
Fee-for-Service (FFS) plans used to be much more popular than they are now.
However, some insurance providers still offer them.
With FFS plans, enrollees have the most freedom of choice when it comes to selecting their health care providers and care facilities.
They can choose any medical professional at any hospital as long as they pay a certain amount for each service.
In addition, beneficiaries are not required to obtain referrals from their primary care doctors in order to visit specialists.
Moreover, there is no cost difference between visiting an out-of-network versus in-network provider.
Enrollees simply pay the cost upfront and then are reimbursed after their claim is processed.
This plan option is very expensive and as a result, not many residents purchase
About High-Deductible Health Plans
High Deductible Health Plans (HDHPs) can come with a Health Savings Account (HSA) or without one.
These plans offer residents low cost health care to those who are low-risk such as with Catastrophic plans.
HDHPs provide structure like HMOs, PPOs, EPOs and POSs but have much higher deductibles for enrollees to meet.
Additionally, these plans have high out-of-pocket cost limits.
However, setting up an HSA with an HDHP can help enrollees afford this plan. An HSA is a tax-free savings account that can be used toward future medical costs.
The maximum amount that members can deposit is $3,450 or $6,900 for families.