Health coverage is a legal entitlement to payment or reimbursement for health care costs. It can be provided by an employer, private insurer or government program like Medicare and Medicaid.
Most plans have a network of providers, such as physicians and hospitals, that contract with the plan for discounted pricing. They also have deductibles that limit how much you pay before the insurance pays.
PPO
Preferred provider organization (PPO) plans are managed care plans with maximum flexibility. Unlike HMOs, POS plans and EPOs, they do not require you to choose a primary care physician or get referrals before seeing specialists. However, they do incentivize you to stay in-network for the most coverage possible by offering lower copayments for in-network specialists.
Like virtually all managed care plans, PPOs use cost-sharing to keep healthcare costs in check. Cost-sharing involves you paying for healthcare services through deductibles, copays and coinsurance. This is meant to ensure you really need the treatment and are not just using it for convenience or money. It also discourages frivolous healthcare use.
HMO
HMOs offer health coverage at a lower cost than traditional indemnity or fee-for-service plans. You typically pay a monthly premium and meet an annual deductible. You also pay a copayment or coinsurance when you receive care.
Most HMOs have a network of healthcare providers. Your PCP will determine whether you need other types of care, such as specialists, and if so, will make referrals.
Some HMOs allow you to visit out-of-network specialists without a referral, but this usually comes at a higher cost. They are also generally limited to a geographic area. However, emergency and urgent care is covered even when it is received outside the network.
EPO
An EPO is a type of health insurance plan that limits your care to in-network providers. This allows the insurance company to negotiate lower costs for your medical treatment. However, you still pay for some of the costs, such as a deductible, copayment or coinsurance, depending on your plan.
Most EPOs require you to select a primary care physician (PCP), but they don’t require referrals from PCPs for specialist visits, as some HMOs do. Most also allow you to visit out-of-network hospitals for true emergencies, but those visits may be subject to higher cost-sharing rates than if the hospital was in-network. You should always review your plan’s specifics to be sure.
POS
POS health plans are a good option for individuals who want the flexibility of going out of network, but also like the affordability of PPOs. These plans have low deductibles and copays, especially if you see doctors and medical facilities that are in network.
However, you’ll pay higher out-of-pocket costs if you go outside of your plan’s provider network without a referral from your primary care doctor. To get the best value from your POS health insurance, be sure to keep all receipts for doctor visits and submit them to your insurer when you’re ready for reimbursement. eHealth makes it easy to compare POS health plans and find the right one for your needs and budget.
Bronze
Most health plans offered through the marketplace are categorized by their metal level. These metal levels represent how much you pay for deductibles, copays and other out-of-pocket costs. The plan you choose will also affect your monthly payments, or premiums. Bronze plans generally have the lowest monthly payments, but Silver plans are usually more expensive unless you qualify for a cost-sharing subsidy.
A bronze plan is a good choice if you’re healthy and only need minimal coverage, such as a yearly checkup and prescription drugs. However, remember that a bronze plan’s deductibles can be very high. If you want to avoid large out-of-pocket expenses, consider a Silver plan or higher.
Silver
A Silver health plan is the mid-range option on the marketplace/exchange. In general, unsubsidized Silver plans pay on average about 70% of an enrollee’s healthcare costs. Those costs are comprised of copayments and coinsurance.
Health insurance plans on the exchanges are grouped into different metal levels to make it easier to compare options. However, the pricing varies widely from one company to another, so it is important to shop around.
Silver plans also offer a higher level of benefits and cost-sharing reductions than other metal tiers. However, since the federal government has ended Cost-Sharing Reduction payments, premiums have gone up. However, a premium subsidy can help with this.
