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Different Types of Health Plans: How They Compare

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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.

  • Platinum: covers 90% on average of your medical costs; you pay 10%
  • Gold: covers 80% on average of your medical costs; you pay 20%
  • Silver: covers 70% on average of your medical costs; you pay 30%
  • Bronze: covers 60% on average of your medical costs; you pay 40%
  • Catastrophic: Catastrophic policies pay after you have reached a very high deductible ($7.350 in 2018). Catastrophic plans must also cover the first three primary care visits and preventive care for free, even if you have not yet met your 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:

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 can doctors who treat you in the hospital can bill you.

  • 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 except for preventive care.
  • 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.

  • 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.

  • 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.

  • Premium: This is the cost you pay each month for insurance.
  • Deductible: A catastrophic health plan has a deductible of $7,350 for an individual and $14,700 for a family in 2018. 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 to show you have met 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

  • Premium: An HDHP generally has a lower premium compared to other plans.
  • Deductible: The deductible is at least $1,350 for an individual or $2,700 for a family, but not more than $6,650 for an individual and $13,300 for a family in 2018. Like with al plans, your preventive care is free even if you haven’t met the deductible.
  • Copays or coinsurance: Other than preventive care, you must pay all your costs up to your deductible when you go for medical care. You can use money in your HSA to pay these costs.

You can set up a Health Savings Account to help pay for your costs. The maximum you can contribute to an HSA in 2018 is $3,450 for individuals and $6,900 for families.

Paperwork involved. Keep all your receipts so you can withdraw money from your HSA and know when you’ve met your deductible.

Fair Health, Inc.: “Alphabet Soup of Health Plans” and “Understanding High-Deductible Health Plans.”

The Henry J. Kaiser Family Foundation. “Health Reform FAQs: Marketplace Eligibility, Enrollment Periods, Plans and Premiums.”

Society for Human Resource Management: “For 2015, Higher Limits for HSA Contributions and Deductibles.”

Internal Revenue Service.

Life and Health Insurance Foundation for Education: “What are the Different Types?”

Minnesota Medicine, February 2011: “Five Payment Models: The Pros, the Cons, the Potential.”

Office of Personnel Management: “Healthcare Plan Information” and “2013 High-Deductible Health Plans with Health Savings Accounts/Health Reimbursement Arrangements.”

Posts tagged “POS”

Pay a Higher Deductible or a Higher Premium?

It’s the ultimate insurance debate: pay a higher deductible or higher premium? With many employers looking for ways to cut costs, the question to increase your monthly health insurance premiums or to pay a higher deductible is a concern you may be facing sooner rather than later.

First, let’s clarify the difference between a premium and a deductible.

  • A premium is the amount of money charged by your insurance company for the plan you’ve chosen. It is usually paid on a monthly basis, but can be billed a number of ways. You must pay your premium to keep your coverage active, regardless of whether you use it or not.
  • A deductible is a set amount you have to pay every year toward your medical bills before your insurance company starts paying. It varies by plan and some plans don’t have a deductible.

In 2017, more employers than ever included a high-deductible option on their 2017 menu of health plan offerings. An August survey of 600 U.S. companies by benefits consultancy Willis Towers Watson found that by 2018, nearly half will offer these plans exclusively. In 2006, high-deductible plans covered just 3 percent of workers. Fast-forward to 2016, and that figure was 29 percent, benefits consultancy Mercer found.

High Deductible Health Plans (HDHPs): Pros and Cons

HDHPs work differently than traditional POS (Point of Service) or PPO ( Preferred Provider Organization) plans in that all healthcare expenses are paid out-of-pocket until the deductible is met. The concern with high deductibles is that it causes patients to not seek medical treatment because they fear the expense. Ultimately, this causes more extensive issues later on, such as those relating to diabetes, hypertension, depression, even cancer.

  • Premiums are typically lower than with POS or PPO plans
  • Networks are not necessarily narrowed, as with HMOs
  • People who rarely use their health benefits may save money
  • If you are not on expensive medications, your monthly bills may be lower
  • Out-of-pocket expenses are not the market rate, but the negotiated rate between the healthcare provider and insurance company
  • Policyholders can open a health savings account (HSA), which never “expires,” to help cover out-of-pocket expenses
  • People managing chronic illnesses find that their out-of-pocket expenses are high
  • Prescriptions, office visits, and diagnostic tests are completely out-of-pocket until you reach your deductible
  • If you need surgery, you will need to hit your deductible before the insurance company will pay anything
  • If your monthly out-of-pocket expenses are high, you aren’t taking full advantage of your HSA
  • Your deductible can be quite high (sometimes as much as $13,000 for families)

Those who initially lean toward higher insurance premiums are usually looking to save money in the long run, while those who originally gravitate to the higher deductible plans are looking to put more money in their pockets right now. However, sometimes it’s not that simple.

A 2011 study by the Kaiser Family Foundation found American families are increasingly paying more and more out of pocket for their health care costs – a whopping $15,073 for a family health insurance plan. However, it’s unlikely you’ll pay that full amount. With most employer-sponsored health care plans, your company pays a hefty dose of the premiums.

The Bureau of Labor Statistics reports that in 2008, private sector companies paid as much as 71 percent of family health insurance premiums. Public sector employers dished out even more – up to 73 percent.

While a high deductible plan and its subsequent lower premiums can put more money in your pocket, as well as your employer’s pocket, right now, it isn’t always the best choice. The Kaiser Family Foundation study also determined that the average deductible on these consumer-driven plans was nearly double that of traditional health insurance. On top of that, plans with a high deductible often come with a higher out-of-pocket max as well, sometimes as high as $10,000 a year for a family insurance plan.

Which plan is right for you?

As health insurance is not a one-size fits all item anymore, each person has to weigh the pros and cons of high deductible health plans against how they might need to use the policy. A person without an extensive medical history and unmarried without children might be able to risk such a plan. However, if an individual or someone in the family sees a doctor once a month or needs to manage a medical or mental condition, perhaps a PPO would be a better.

Ultimately, choosing the right plan for you and your family can seem like you’re gambling with both your health and your money. If you are unsure of the insurance plan your company is offering you, a licensed insurance agent can assist you in finding a plan directly from the best health insurers.

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Family Health Insurance

The hard part about getting health insurance coverage is finding the right plan — especially for families.

There’s a lot to think about when it comes to a family health insurance plan, so it helps to understand how health insurance works and to know your family plan options.

Let’s take a look at a few.

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What Are Some Affordable Family Health Insurance Options?

Health insurance for your family can actually be more affordable than you think. But not every plan costs the same — that’s why it’s best to compare benefits and rates to find the plan that’s right for your budget.

Managed care plans are popular choices for affordable family health insurance. They create networks of doctors, hospitals, clinics, specialists, and other health care professionals — all who provide their medical services at discounted rates. For you and your family, that means lower health plan costs — including more affordable premiums, copayments, and coinsurance.

What are the most common kinds of managed care plans?

    PPOs (Preferred Provider Organization). The PPO plan provides flexible coverage. You and your family will save money when going to a preferred in-network physician, but you’ll also have coverage with out-of-network doctors. For comprehensive, flexible, and affordable coverage, the PPO is a popular choice for family health insurance.

HMOs (Health Maintenance Organization). The HMO is one of the most affordable kinds of managed care — and another common family health insurance choice. Copayments can be as low as $10, and many HMOs don’t require a deductible. You choose a primary care physician from your HMO network, and they’ll be the first doctor you go to for care. If you or a family member needs specialist care, your primary care physician will need to give you a referral. The only downside to HMO plans is that you can only receive care from providers who participate in-network — services are not covered outside the HMO network.

  • POS (Point Of Service) Plans. The POS plan combines elements of an HMO and PPO together. Like an HMO, you’ll choose a primary care physician from the preferred network as your “first line of defense” doctor. Like a PPO, you’ll have coverage with any health care provider — inside or outside of the network.
  • On kind of health plan that’s not optimal for family health insurance is a traditional FFS (Fee-For-Service) plan. FFS plans aren’t managed care, and don’t work with any health care provider networks.

    On one hand, FFS plans might seem attractive — you have equal coverage with all doctors and hospitals, and most health care services are covered. But for families, they’re not the optimal choice. FFS plans are the most expensive kind of health insurance, and many don’t provide coverage for preventive care.

    Consider a managed care family health insurance plan before traditional FFS coverage.

    Individual vs. Family Coverage

    For complete family health insurance, you have a few basic coverage options. The managed care plans above can be tailored to your family’s needs — for customized coverage or basic protection.

    Individual plans for every family member.
    This is the best family health insurance option for families whose members have different health needs. If a member has a chronic illness such as diabetes or asthma, individual plans could be the most cost-effective way to go.

    Because insurance companies set rates according to health, a pre-existing condition could drive premiums up for everyone. But with individual plans, family members who don’t need frequent medical care are on separate plans — and can keep low rates.

    Cover everyone with your individual plan.
    Some insurance companies will allow you to add family members under your individual coverage. If your family needs coverage for routine and emergency care, this is a good option to consider. Covering everyone with one individual family health insurance plan is usually most affordable if everyone has similar health needs.

    Get expert advice from a professional agent to see which family health insurance option is best for you and your family. It’s easy to add your family to your quotes — you just need to enter their gender, date of birth, height, and weight.

    Preventive Care: It’s Extra-Important For Children

    Health insurance gives you peace of mind that your children will always have access to health care. But it’s also important to make sure they go in for regular doctor check-ups and booster shots to make sure they grow up strong.

    That’s why coverage for preventive care is vital to ensure your children stay healthy. Health insurance makes the preventive care they need affordable — and can catch early signs of illness before they turn into serious conditions.

    Most managed care family health insurance plans provide coverage for preventive care such as:

    • Routine doctor’s check-ups
    • Physicals
    • Immunizations and vaccinations
    • Well-baby care

    With managed care plans, visits to the doctor, prescription drugs, and wellness care can cost as low as $10. Some family health insurance plans, such as HMOs, even provide many preventive care services for no extra cost.

    Preventive care is very important for children, but it’s also important for everyone else! Having coverage for routine doctor’s check ups and physicals is a good idea so you can always stay on top of your health.

    Also remember that if you are planning on starting a family or adding another member to the family in the near future, you should make sure that the family health insurance plan you choose includes maternity care. This will make your plan a bit more expensive, but the coverage during pregnancy to ensure the health of both the child and the mother is invaluable.

    Finding the Right Health Plan For Your Family

    Now that you’ve learned a little bit about family health insurance, we can help you find the right coverage.

    Connect with professional agents for expert advice — absolutely free. Our online service at GoHealthInsurance.com will provide you with free quotes from agents representing the top names in health insurance. Just fill out our secure form — it’s 100% risk-free and you have no obligation to buy anything.

    Take advantage of our agents’ expert advice, and get the family health insurance plan you’ve been looking for.

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