How to Choose Your Health Insurance

How to Choose Your Health Insurance

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Step 1: Find your marketplace

The first step in choosing the proper health insurance is determining where you are going to get your insurance. You can use your employer, a government run exchange, or a different marketplace.

A majority of individuals get their health insurance through their employer, since that is usually the least expensive option because their employer pays a portion of the premium.

Even if your employer offers health insurance, you can still choose a plan that is not offered by your employer. Many people look on state government health insurance exchanges. In addition to typically offering a large selection of plans, purchase on these exchanges may come with premium subsidies if you are eligible.

You can also choose to look for a health insurance plan on private exchanges or directly with insurers. Subsidies that you may be eligible for because of your income will not be available if you choose to use a private exchange or a direct insurer to locate a health insurance plan.

Step 2: Compare the types of health insurance plans

Comparing the different types of insurance plans is crucial, because the type of plan you choose dictates out-of-pocket costs and which physicians, hospitals and services are covered under your insurance. A benefits summary will help you compare the different health plans because it provides a concise list of cost and which doctors are covered in your network.

Comparing types of health insurance plans: HMO vs. PPO vs. EPO vs. POS

Health insurance plans come in many different styles.

Health Maintenance Organization (HMO)

With an HMO plan, you pick a single primary care physician who manages all your health care. That means you need a referral before seeing any other health care professional, except in an emergency. HMOs give you access only to doctors and hospitals which are in their network. If you see a physician outside the network, you’ll have to pay the entire cost. HMO plans generally have lower premiums, and there is usually no deductible or a low one.

Preferred Provider Organization (PPO)

PPOs also use a network of providers like HMOs do, but there are fewer restrictions on seeing non-network providers and you don’t need to choose or get referrals from a Primary Care Physician. Reimbursement for out-of-network care is usually at a lower rate than for in-network care. Premiums tend to be higher, and it’s common for there to be a deductible.

Exclusive Provider Organization (EPO)

EPOs are similar to PPOs. You won’t need referrals to see a specialist or need to choose a primary care physician. But you will have a limited network of hospitals and doctors to choose from. EPO plans don’t cover care outside your network unless it’s an emergency.

Point of Service (POS)

Point of Service (POS) plans combine elements of HMOs and PPOs. Like an HMO, you are required to choose a primary care doctor and to get a referral before visiting a specialist. In-network care usually has a low co-payment and no deductible. Like a PPO, you can also use physicians who are not in the network, but you will reimbursed at a lower rate.

Comparing types of health insurance plans: HMO vs. PPO vs. EPO vs. POS

Plan Type Do you have to stay In Network? Do specialists or procedures require a referral? Benefits
HMO Health Maintenance Organization Yes (except emergencies)  Yes
  • lower out-of-pocket costs
  • primary care doctor that coordinates tests and specialists
PPO Preferred Provider Organization No (but in-network is less expensive) No
  • more provider options
  • no required referrals
EPO Exclusive Provider Organization Yes (except emergencies) No
  • lower out-of-pocket costs
  • no required referrals
POS Point of Service Plan No (but in-network is less expensive and you need a referral to go out of network) Yes
  • lower out-of-pocket costs
  • primary care doctor that coordinates tests and specialists 

Step 3: Compare health plan networks

The vast majority of insurance plans offer in-network provider services at lower cost, so if you want to continue to see a specific doctor you need ensure they are in your coverage network. A larger coverage network increases the number of doctors available for you to see, which can make getting health care easier.

Step 4: Compare out-of-pocket costs

The benefits summary of available health insurance plan should be listed on the marketplace you use. You are responsible for paying the deductible, coinsurance, and copayments for your health insurance plan. Every health insurance plan also has a maximum annual out-of-pocket cost that you have to pay, but the lower your monthly premium, typically the higher that maximum cost is.

Plans that pay a higher portion of your medical costs, but have higher monthly premiums, are better if:

  • You see a frequently see a doctor, whether a primary physician or a specialist

  • You need emergency care frequently

  • You take brand-name or expensive medications on a regular basis

  • You plan to have a baby, are expecting a baby, or have small children

  • You have surgery planned

  • You’ve been recently diagnosed with a chronic condition such as cancer or diabetes

Plans with higher out-of-pocket costs and lower monthly premiums are the better choice if:

  • You can’t afford higher monthly premiums for a plan with lower out-of-pocket costs

  • You are in good health and rarely see a doctor

Step 5: Compare benefits

After narrowing down your list of health insurance plans you should compare the benefits provided by each plan to ensure that you choose the plan that provides coverage for the services you need most. After your new health insurance begins you must make sure that your previous plan is discontinued.

Health Insurance Quality Categories

All these different types of health insurance can be offered in the four standard categories of health insurance: Bronze, Silver, Gold, and Platinum. Each category indicates how much of your costs will be paid by your insurance company:

  • Bronze plans cover 60% of estimated typical annual medical costs

  • Silver plans cover 70%

  • Gold plans cover 80%

  • Platinum plans cover 90%

The price of premiums increase the more medical costs your insurance company covers, but your maximum out of pocket expenses decreases the more medical costs your insurance company covers.

You may be eligible for a premium subsidy based on your income through a tax credit.

Catastrophic health plans are alternatives to the four standard insurance plans. Catastrophic plans have low premiums and extremely high deductibles. They are designed to leave you paying for the bulk of your routine medical costs, but provide backup if you experience serious medical conditions, like a heart attack or cancer.

Important Healthcare Terminology and Costs

  • Deductible:

    The amount of money you have to spend for health services before your insurance company pays anything (except free preventive services)

  • Copayments and coinsurance:

    Payments you make each time you get a medical service after reaching your deductible

  • Out-of-pocket maximum:

    The most you have to spend for covered services in a year. After you reach this amount, the insurance company pays 100% for covered services.