When shopping for health insurance plans you have a variety of options. These options will fall under a few categories, major medical and those that are not major medical. Major medal plans follow the compliance of the Affordable Care Act (ACA). These are your EPO, HMO, POS, and PPO types of networks. Government-sponsored plans such as Medicare and Medicaid also fall under major medical. Non-major medical will be types of insurance such as short-term, GAP, Accident, and critical illness.
Let's start by going over ACA-compliant plans found on the marketplace exchange. These will be considered major medical plans and must offer minimum essential coverage. These plans are also the ones that can not deny you for a preexisting condition.
Major medical plans on the marketplace will be separated into 4 metals (categories): Bronze, Silver, Gold, and Platinum. There are also catastrophic plans available to those under the age of 30 or older people with a hardship exemption. All 4 plans are based on an actuarial value which is defined as the average percentage of health care expenses the plan will pay. The higher the actuarial value the more the plan pays toward your bills.
What are the metal levels?
Bronze
*Covers around 60% of medical cost *Lowest monthly payments *Higher cost when needing care
Bronze plans keep your monthly costs (premiums) down and are best if you don’t have a lot of health needs.
Silver
- Covers around 70% of medical costs
- Moderate monthly premiums
- Deductibles are usually lower than a bronze plan
If you qualify for a cost-sharing reduction (CSR) you must pick a silver plan to get extra savings. This can save you hundreds or even thousands each year.
Gold
- Covers around 80% of medical costs
- High monthly premiums
- Lowest cost when you get care
Gold is great if you regularly use healthcare or have an ongoing need for prescriptions.
Platinum
- Covers around 90% of medical costs
- Highest monthly premiums
- Lower deductible allows the plan to pay their share earlier than other plans
This plan covers the maximum amount of coverage. It is necessary for those that have a lot of medical needs throughout the year.
Plan types
The most common types of major health insurance plans are HMO, PPO, EPO and POS. These plans may vary depending on your area but all will offer the 4 different metal tears. Each plan type differs in terms of its network and coverage options, which determine which doctors you may see and how much you'll have to spend.
HMO (Health Maintenance Organization)
An HMO plan will provide comprehensive and wellness care but will restrict you to in-network care. Some features of an HMO you may have:
- Allows you to pick an in-network primary care physician. If you need a specialist you will more than likely need your primary care physician to issue you a referral.
- Generally won't cover out-of-network care unless it is an emergency.
- Smaller network coverage than other plan types
PPO (Preferred Provider Organization)
A PPO insurance plan offers the greatest advantages if you see a doctor or other provider who is in its provider network, but it also offers limited coverage for outside-the-network providers. Additionally, you typically do not need a referral from your primary care physician to see any specialist. Some features of an PPO you may have:
- Low in-network cost to see a doctor but a higher cost to see an out-of-network provider.
- More freedom to choose a doctor. There is no commitment when choosing a primary care physician.
- You do not need a referral from your primary care physician to see a specialist.
EPO (Exclusive Provider Organization)
An EPO plan offers a more localized network of doctors and health providers. These plans usually offer a more affordable premium. However, going outside of the plan's network is not usually covered (the exception would be emergency care). Some features of an EPO you may have:
- More freedom to choose a doctor. There is no commitment when choosing a primary care physician.
- You do not need a referral from your primary care physician to see a specialist.
- Lower premiums but often a higher deductible.
POS (Point of Service)
A POS plan is a nice mixture of an HMO and a PPO. A member must select a primary care physician and request referrals to network specialists, just like with HMO plans. Similar to PPO insurance, members can choose to receive care from providers outside of the network, but doing so may result in higher out-of-pocket expenses. Some features of a POS you may have:
- More freedom to choose a doctor. There is no commitment when choosing a primary care physician.
- Ability to see an out-of-network specialist. Claim forms will need to be filed and a referral given by your primary care physician.
- Monthly premiums are lower than a PPO and most plans offer a zero deductible.
Catastrophic Plans
Catastrophic plans offer cheap monthly rates but very high deductibles. This means that the majority of medical expenses will only be covered by the insurer after the deductible has been met. You must pay the whole cost of your medical care before reaching your deductible. Here are some features of a catastrophic plan:
- After the deductible is met, the insurance company will pay all or most of any covered medical expenses including hospitalizations and surgeries.
- Preventative care such as vaccinations, screenings, and annual checkups
- 3 free primary care visits per year.
Note: There are no ACA subsidy payments that can be used to reduce the cost of catastrophic health insurance plans. A typical bronze- or silver-level plan may be less expensive and provide greater coverage than a catastrophic plan if you are eligible for a subsidy.
Non-major medical
Plans found off of the marketplace do not follow the same guidelines as the Affordable Care Act (ACA). These non-major medical plans often are less expensive than marketplace plans but with fewer coverage options. These plans can come in many forms and can also be beneficial when adding to a marketplace plan.