UPDATED: SEPTEMBER 18, 2023 | 3 MIN READ
Health insurance plans come with choices, and costs without healthcare are astronomical. If you’re in the market to look for healthcare plans, you’ll see all kinds of options. It can feel confusing and overwhelming.
So, how are the plans different? The article below covers all types of health insurance plans available, deductibles, costs, and more to help you identify the best plan for yourself and your family.
Types Of Health Insurance Plans
There are common types of health insurance plans within each category. Each one has a set of shared costs and different deductibles. Insurance brands within each level can change, with some more common national brands including Blue Cross Blue Shield, Aetna, or Cigna.
The main categories of healthcare plan types are Health Maintenence Organizations (HMOs), Preferred Provider Organization (PPOs), Exclusive Provider Organization (EPO), Point of Service Plan (POS), Catastrophic Plan, and High-Deductible Health Plan with or without Health Savings Accounts (HSA).
Health Maintenance Organization (HMO)
HMO plans deliver health services through a network of providers and facilities. As a result, an HMO plan offers the least amount of freedom to choose your healthcare providers and the least stress when it comes to paperwork.
What doctors can you see?
A primary care physician manages your overall care, and HMOs require specialist referrals. You can see any provider within the HMO network, so if you visit a provider outside of the network, you most likely pay the total bill out of pocket.
Emergency visits also need to stay within the network. Non-participating doctors who treat you in the hospital can bill your HMO insurance.
What you pay
- Premium: Your monthly payment for insurance
- Deductible: HMO plans might require a deductible before covering the rest of your care, except for preventative care like colonoscopies.
- Co-Pay and/or Co-Insurance: Co-pays are flat fees you pay upfront when you receive care. Coinsurance is paying a percentage after you receive care. Both charges may vary depending on your HMO plan and are counted towards the deductible.
Paperwork Involved
HMO plans are the easiest when it comes to paperwork. There are no claim forms necessary to fill out.
Preferred Provider Organization (PPO)
With a PPO plan, you can choose your healthcare provider more freely than with an HMO. You don’t need a referral from your primary care provider to see a specialist. However, there are higher out-of-pocket prices if you choose an out-of-network provider.
What doctors can you see?
You can see any doctor within the PPO network, but you can see out-of-network doctors, too.
What you pay
- Premium: Monthly payment for your insurance.
- Deductible: Some PPOs have deductibles, more likely if you visit an out-of-network provider.
- Co-Pay and/or Co-Insurance: Your copay is a flat fee you pay when receiving care, and coinsurance is paying a percentage of the total charges for your care
Paperwork Involved
Some paperwork may be associated with a PPO, but not usually if you see an in-network doctor. Out-of-network providers need payment; you must file a claim to get reimbursement from the PPO plan.
Exclusive Provider Organization (EPO)
EPOs give you more freedom in choosing your provider, and you don’t need a referral to see a specialist. However, with an EPO plan, there is no coverage for out-of-network providers, so you pay the total cost.
What doctors can you see?
You can see any provider within the EPO’s network.
What you pay
- Premium: Monthly payment for your insurance.
- Deductible: Some EPOs have a deductible.
- Co-Pay and/or Co-Insurance: Your copay is a flat fee you pay when receiving care. With coinsurance, you pay a percentage of the total charges for your care.
- You pay in full if you see a provider out of the EPO network.
Paperwork Involved
There is little to no paperwork with an EPO plan.
Point Of Service Plan (POS)
POS health insurance plans are a combination of an HMO with a PPO. You have more freedom in choosing your providers than with an HMO and a primary care doctor who refers you to specialists when needed.
What doctors can you see?
You can see POS in-network providers and your primary care doctor. If you visit an out-of-network provider, there is a higher cost.
What you pay
- Premium: Your monthly insurance payment.
- Deductible: POS plans typically require deductible payments before covering care. Your deductible is higher if you see an out-of-network provider.
- Co-Pay and/or Co-Insurance: POS plans have either a co-pay or coinsurance, not both. Your co-pay or coinsurance is also more costly when you use an out-of-network doctor.
Paperwork Involved
Paperwork is necessary, especially when you visit an out-of-network provider. You must pay the bill in full and submit a claim to your insurance company for reimbursement.
Catastrophic Plan
Catastrophic plans are for those under the age of thirty. These plans offer lower premiums, up to three visits before paying a deductible, and free preventative care.
What doctors can you see?
You can see any doctor within the Catastrophic Plan’s network. However, there may be additional rules when seeing a specialist.
What you pay
- Premium: The cost you pay monthly for insurance.
- Deductible: Catastrophic plans have high deductibles; it is $8,150 for an individual and $16,300 for a family. Once the deductible amount is reached, the plan pays 100% of medical costs for covered benefits.
- Co-Pay and/or Co-Insurance: There is no co-pay or coinsurance with a Catastrophic Plan.
Paperwork Involved
Paperwork is necessary under the Catastrophic Plan. You must save receipts and payment information to prove you meet the deductible.
High-Deductible Plan (With or Without an HSA)
High-Deductible Plan (HDHP), with or without a Health Savings Account (HSA), allows you to pay less for insurance. You can have an HMO, PPO, EPO, or POS plan with an HDHP plan. There are higher healthcare costs than other plans, but once you reach the maximum limit, the plan pays 100% of your care.
The health savings account (HSA) – also called a Flexible Spending Account (FSA), is a way to help pay for your care. It is money you put free of tax to utilize for medical expenses.
What doctors can you see?
Depending on the type of plan you choose – HMO, PPO, POS, or EPO – the selection of health care providers can vary.
What you pay
- Premium: HDHP plans have lower premiums compared to many other healthcare plans.
- Deductible: Deductibles are high – you pay at least $1,400 for an individual and $2,800 for a family. The maximum for an individual is $6,900 and for a family is $13,800, except for preventative care, which is free if you haven’t met the deductible.
- Co-Pay and/or Co-Insurance: Depending on your plan, you have varying costs for co-pays and coinsurance.
Paperwork Involved
The paperwork is extensive. You need to keep track of all receipts and medical payments, especially when withdrawing from your HSA, so you can prove you meet the deductible.
Types of Health Insurance Plans From the Marketplace
Plans in the marketplace are usually presented in the following healthcare categories: bronze, silver, gold, and platinum. Catastrophic plans are also available to some. Costs can vary, but most percentages are standard for each plan.
Bronze health insurance plans
A bronze health insurance policy covers the least amount of medical costs at 60%, and you pay 40%. However, they do have the lowest monthly premiums.
Silver health insurance plans
The insurance company pays 70% of your healthcare costs with a silver plan. You are responsible for paying 30%. If you qualify for cost-sharing reductions, you must pick a silver plan to be awarded the extra savings.
Gold health insurance plans
Gold plans cover 80% of your medical costs, and you are responsible for paying 20%. Therefore, they are an excellent choice for those who use a lot of care or need frequent healthcare visits.
Platinum health insurance plans
With a platinum insurance plan, the insurance company pays 90% of medical costs, and you are responsible for only 10%. However, they also have the highest monthly premiums.
Catastrophic health insurance plans
Catastrophic policies pay after you reach a very high deductible amount. They also cover the first three primary care visits and preventative care for free, even if you haven’t yet met the deductible.
Medicaid and Medicare
Medicaid and Medicare are two separate government-run programs for your healthcare. Their primary service is geared towards different groups. As a result, there are differences in covered healthcare benefits and cost-sharing.
What’s Medicaid, and who’s it for?
Medicaid is a state and federal-funded program to provide health insurance coverage to anyone with a very low household income.
What’s Medicare, and who’s it for?
Medicare is a federal program providing healthcare to anyone over 65. You are also eligible for Medicare coverage if you are under 65 and have a disability. Those not eligible or too young for Medicare can look at plans from the ACA Marketplace.
Can you have Medicaid and Medicare?
If you are eligible for both, you can have Medicaid and Medicare healthcare plans. They work together and provide you with coverage as well as lower costs.
FAQs
What’s the difference between HMO and PPO?
The most significant difference between an HMO and a PPO plan is with an HMO plan; you are more restricted to a specific network of healthcare providers. You also need referrals for specialists from your primary care physician with an HMO. PPO plans allow you to choose any doctor within or outside the network.
What is the best type of health insurance for individuals?
Individuals have multiple healthcare plans to choose from. Even if you’re pretty healthy, various plans can work for you. Take time to weigh options and factor your health needs and costs into choosing the best type of individual health insurance plan.
What are two major types of health insurance?
The two major types of health insurance are private and public. With public health insurance like Medicare, the government provides your plan. Private health insurance includes plans you get through your employer or the marketplace. There are specific enrollment periods for each.
Which is better, PPO or HMO?
HMO plans tend to have lower monthly premiums than PPOs, and you can expect to pay fewer out-of-pocket costs. However, PPOs have more flexibility in choosing your provider. Therefore, either plan can be beneficial based on your healthcare needs.
What are the four types of health insurance?
The four types of health insurance are Health Maintenance Organizations (HMOs), Exclusive Provider Organizations (EPOs), Point Of Service (POS) plans, and Preferred Provider Organizations (PPOs).
What happens if you lose Medicaid?
If you’re income increases and you lose Medicaid, you have options. You’ll have a Special Enrollment Period to select a new healthcare policy.
Finding Your Health Insurance Plan
Different types of health insurance plans are geared to meet different health needs. First, compare health insurance plans and look for a summary of health benefits to explore health care services.
Then, weigh your or your family’s medical care needs, and consider whether you want a referral system of care. Address any lingering questions or concerns you have with insurance providers. Then, determine the health coverage necessary and find a plan to fit your needs.
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