Types of Health Insurance Plans

All health insurance plans work by partnering with a network of healthcare providers like doctors and hospitals. But the way that these plans work within the networks varies between HMOs and EPOs.

HMO: Health Maintenance Organization

HMO Plans are the most restrictive type of plan when it comes to accessing your network of providers. You must choose an in-network primary care physician (PCP), and then all of your care will be coordinated through that PCP to other in-network providers. So if you need a specialist, such as a cardiologist (heart doctor), you’ll need a referral from your PCP first. HMOs do NOT cover any out-of-network healthcare costs, except in an emergency.

An HMO plan may require you to live or work in its service area to be eligible for coverage, and they typically have cheaper premiums than other types of private health insurance plans.

EPO: Exclusive Provider Organization

EPO Plans are more flexible than HMO plans in that you are typically able to see a specialist without a referral. (You may need a referral for surgeons and other very specific specialists.) Like HMO plans, EPO plans do NOT cover any out-of-network healthcare costs, except in an emergency.

Note for Parents: Children under age 26 are allowed to stay on their parent’s health insurance plan; however, if they are going to school or live out-of-state, it may not be a good idea. Most health insurance plans have a provider network that is limited to a specific local area and therefore won’t work out-of-state.

Health Savings Account (HSA) Plans

HSA plans give you the most control on how your healthcare dollars are spent. They tend to have lower monthly premiums and higher deductibles. If you have a HSA Plan, sometimes referred to as a High Deductible Health Plan (HDHP), you are able to set up a Health Savings Account, a type of savings account that allows you to set aside money on a pre-tax basis to pay for qualified medical expenses. This is important because with HSA plans, your insurance company doesn’t pay any of the medical costs until the deductible is met, but by using the untaxed funds in an HSA to pay for these expenses, you can reduce your overall healthcare costs.

HSA funds roll over year to year if you don’t spend them. And, an HSA may earn interest. You can open an HSA through your bank or other financial institution.

If you are unsure which type of plan is right for you, have one of our certified Brokers walk you through it.

Coverage Levels (or Metal Tiers)

Health plans are arranged into four levels – Platinum, Gold, Silver and Bronze – to help you narrow your options based on your budget and health needs. These levels show, on average, how much of the cost of medical services is covered by the health insurance company and how much is paid for by the customer.

These percentages reflect the estimated amount of cost paid by you versus paid by the health insurance company considering the plan as a whole, taking into account the deductible, coinsurance, and copayments, as described by the specific details of the plan and based on the anticipated average use of the plan. These percentages do not take premiums into account, nor do they represent the exact amount that you’ll actually pay for healthcare services.

Platinum and Gold plans will generally have the highest monthly premiums, while the customer will pay the least when receiving medical care. Bronze plans will generally have the lowest monthly premiums, while the customer will pay the most when actually receiving medical care. You can choose the level of coverage that works best for you.

Catastrophic Health Plans

There is a fifth category you may see in the Marketplace called “catastrophic” plans. Catastrophic plans have a low monthly premium and very high annual deductible and are designed to protect customers from high-cost, worst-case situations like a serious injury or illness. This type of plan is available to individuals under age 30 on the first day of the plan year, and may also be available for certain Coloradans with low incomes who have received a certificate of exemption from the federal shared responsibility requirement based on hardship and affordability.

Catastrophic plans are required to cover the same essential health benefits as other Marketplace plans, including certain preventive services at no cost when delivered by an in-network provider. They also cover at least three primary care visits during the plan year, but consumers pay all other medical costs until the annual deductible is met. Then the plan pays 100% for covered services for the rest of the plan year. Premium Tax Credits and Cost-Sharing Reductions may NOT be used with this type of plan.

 

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