Different Types of Health Insurance Plans: How They Compare in USA

Types of Health Insurance: When it comes to health insurance, you have options. If you purchase health insurance through your state’s Marketplace or through an insurance broker, you will be able to select from bronze, silver, gold, and platinum health plans. Bronze policies provide the least coverage, whilst platinum plans provide the most. If you are under the age of 30, you may be able to purchase a high-deductible, catastrophic plan.

Related – What is Health Insurance and its Types

Types of Health Insurance Plans

What distinguishes the plans? – Each pays a fixed portion of the expenditures for the typical registered person. The specifics of each plan may differ. Furthermore, deductibles (the amount you pay before your plan covers 100% of your health-care costs) vary per plan, with the least expensive having the largest 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 ($8,700 in 2022).  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.

Insurance companies are also linked to different levels of treatment. Aetna, Blue Cross Blue Shield, Cigna, Humana, Kaiser, and United are examples of significant national brands.

Each insurance company may provide one or more of the following four types of plans:

  • Health maintenance organizations (HMOs)
  • 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 moment to consider how these plans differ. Knowing the different sorts of plans might help you choose one that fits your budget and meets your health-care needs. Examine the summary of benefits for a brand’s unique health plan to learn more about it.

Health Maintenance Organization (HMO)

An HMO provides comprehensive health care through a network of healthcare providers and facilities. You may enjoy the following benefits with an HMO:

  • The least amount of choice to select your health-care providers
  • In comparison to other plans, this one requires the least amount of documentation.
  • A primary care physician will oversee your care and recommend you to specialists as needed so that the service is covered by your health plan; most HMOs will demand a referral before you may see a specialist.

What doctors you can see. Any member of your HMO’s network. If you see a doctor who is not in the network, you may be responsible for the entire amount. Out-of-network hospitals must cover emergency treatments at in-network rates, but non-participating 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 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)

You may have more freedom to choose your health care providers with a PPO than with an HMO; you do not need a referral from a primary care doctor to see a specialist.

Out-of-pocket expenses are higher if you see out-of-network doctors rather than in-network providers.

If you visit out-of-network providers, there will be more paperwork than with other plans.

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)

You may have more freedom to choose your health care providers with an EPO than with an HMO; you do not need a referral from a primary care doctor to see a specialist.

There is no coverage for out-of-network providers; if you see a provider who is not in your plan’s network, you must pay the full cost yourself (unless in an emergency).

Lower premiums than the same insurer’s PPO.

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 percentage 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 combines the benefits of an HMO and a PPO. You may have the following options with a POS plan:

  • You have more discretion in selecting your health care providers than you would in an HMO.
  • If you see out-of-network providers, there will be some paperwork.
  • A primary care practitioner who oversees your care and 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.

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