TYPE OF HEALTH INSURANCE YOU MUST KNOW
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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 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 can doctors who treat you in the hospital can bill
you.
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 your essential
benefits. When you have reached those amounts, your
health plan will pay 100% of charges.
Copays and/or co-insurance for each type of care. 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%. These charges vary
according to your plan and they are counted toward your
deductible.
Paperwork involved. There are no claim forms to fill out.
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)
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 percent 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
What doctors you can see. Any in the plan’s network;
individual plans may have additional rules on specialists.
What you pay:
Premium: This is the cost you pay each month for
insurance.
Deductible: A catastrophic health plan has a deductible of
$7,150 for an individual and $14,300 for a family in 2017.
After you reach that deductible, the plan will pay 100% of
your medical costs for covered benefits.
Paperwork involved. You will want to keep track of your
medical expenses before you meet the deductible.
High-Deductible Health Plan With or Without a
Health Savings Account
Similar to a catastrophic plan, you may be able to pay less for
your insurance with a high-deductible
*****health plan (HDHP).
With an HDHP, you may have:
One of these types of health plans: HMO, PPO, EPO, or
POS
Higher out-of-pocket costs than many types of plans; like
other plans, if you reach the maximum out-of-pocket
amount, the plan pays 100% of your care.
A health savings account (HSA) to help pay for your care;
the money you put in an HSA is not taxed and can be
used tax-free on eligible medical expenses. In order to
have a HSA, you must be enrolled in a HDHP.
Many bronze plans may qualify as HDHPs depending on
the deductible (see below).
W hat doctors you can see . This varies depending on the type
of plan -- HMO, POS, EPO, or PPO
What you pay:
Premium: An HDHP generally has a lower premium
compared to other plans.
Deductible: The deductible is at least $1,300 for an
individual or $2,600 for a family, but not more than $6,550
for an individual and $13,100 for a family in 2017. Like
with HMOs and PPOs, your preventive care is free even if
you haven't met the deductible.
Copays or coinsurance: You must review your plans
benefits carefully to learn what you will pay when you go
for medical care.
You can set up a Health Savings Account to help pay for your
costs. The maximum you can contribute to an HSA in 2017 is
$3,400 for individuals and $6,750 for families.
Paperwork involved. The amount of paperwork varies,
depending on whether you get care from a PPO, HMO, or POS
plan. Keep all your receipts so you can withdraw money from
your HSA and know when you've met your deductible.
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