Choosing the right health insurance plan is not at all easy, as individuals need to be aware of a few things that will help them compare all the available health plans. These things are discussed in detail in order to have complete clarity about them.
Metal Categories of Plans
Individual and family health insurance plans offered in the insurance marketplace are available in four metal categories such as Bronze, Silver, Gold, and Platinum. Each metal category of the plan comes with a different premium amount, out-of-pocket expenses and plans in each category suits people with diverse healthcare requirements.
Bronze Plans – Bronze Plans come with the lowest monthly premium but cost more when the insured needs health care. Even the deductibles are high in the Bronze plan and can be thousands of dollars a year. These plans are ideal for people who don’t avail much of health care because the insured need to pay for most of their routine care themselves.
Silver Plans – Silver plans come with a moderate monthly premium and moderate costs when the insured needs medical care. Even the deductibles of Silver plans are usually lower compared to Bronze plans. These plans are ideal for people who qualify for cost-sharing reductions, as they will have extra savings from these plans. People who are willing to pay a slightly higher monthly premium should consider buying these plans because most of their routine care will be covered.
Gold Plans – Gold plans come with a high monthly premium and costs less when the insured needs medical care. Even the deductibles associated with the plans are low. Gold plans are ideal for people who use a lot of medical care, as the high monthly premium of the plans will be balanced out with more of the cost covered for their medical service.
Platinum Plans – Platinum plans come with the highest monthly premium and insured have to pay the lowest cost at the time of receiving medical care. Even deductibles in these plans are low which means that insurance carriers will start paying their share earlier compared to other categories of plans. These plans are ideal for people who use a lot of medical care and are ready to pay a high monthly premium. Nearly all their healthcare cost will be covered.
Different Types of Marketplace Plans
There are different types of health insurance plans available in the insurance market, which are designed to cater to the different needs of the people. Some health plans restrict healthcare provider choices or encourage the insured to get medical care from the plan’s network of hospitals, doctors, pharmacies and other medical service providers. Some plans share greater costs for healthcare providers outside the plan’s network. Some of the types of health plan available in the marketplace include:
PPO or Preferred Provider Organization – PPO plans are the most preferred and popular plan among the individual and family health plans, as these plans offer a wide range of choice in terms of healthcare providers and are more comprehensive in their coverage compared to other individuals and family plans. These plans are known as more comprehensive plans in terms of coverage because most of the healthcare services are included in PPO plans, which are either excluded in other plans or plans charge an extra premium for those services. Members of the PPO plans are free to avail healthcare services from any provider, though out-of-network services will be expensive. Members of these plans have to meet their deductibles before their insurance carriers start to cover or pay the claim amount.
HMO or Health Maintenance Organization – Health Maintenance Organization maintains a network of healthcare providers to provide healthcare services to its members. Healthcare maintains a network of all healthcare entities such as physicians, clinical facilities and specialists, who sign a contract with the HMO to offer a range of medical services to the members on an agreed-upon fee. The monthly premium of HMO plans is low compared to other individual plans but these plans ensure a high quality of healthcare from its network of doctors and hospitals. Individuals receiving healthcare benefits from outside the plan’s network need to pay the entire healthcare cost from their pocket. HMO plans members should first receive healthcare from their primary care physicians, who will manage most of their healthcare needs and also provide a referral to see a specialist.
POS or Point-of-Service – Point-of-Service is a type of plan that comes with the features of both PPO and HMO plans. The benefits of this plan generally depend upon whether the member visit to in-network or out-of-network healthcare providers. members of the plan are required to choose a Primary Care Physician for managing their health issues and to provide a referral before visiting a specialist. Members of this plan can receive healthcare services from out-of-network service providers but they will likely have to pay more just like a PPO plan. The best thing about the POS plan is that these plans do not have deductibles and even the co-payment amount is less for in-network medical services.
EPO or Exclusive Provider Organization – An EPO is a type of managed care health insurance plan in which individuals are allowed to receive healthcare services only from the in-network doctors, hospitals, and other healthcare providers. Members will not receive any coverage on receiving healthcare from outside the plan’s network with the only exception of emergency care. Members of these plans are required to pay some of the cost through co-pays but their insurance carrier will cover some of the healthcare costs, once they pay their deductible amount. Members of the EPO plan need to select a primary care physician, who manages and monitors their health but they do not need to obtain a referral for seeing a specialist physician.
Total Costs for Healthcare
Individuals while choosing a plan should not only think about the monthly premium of the plans but also several other amounts like out-of-pocket costs that have a big impact on the total healthcare cost. Besides their monthly premium, individuals are also required to pay out-of-pocket costs along with deductibles. It is better to understand each and every term carefully.
Deductible – Deductible is the amount that the policyholders have to pay for their healthcare services before their insurance company starts paying anything.
Co-payments and coinsurance – Co-payments and coinsurance is the amount that insured pay each time when they avail a medical service after meeting their deductible amount.
Out-of-pocket maximum – It is the maximum amount that the insured has to spend from their pocket for the covered healthcare services in a year. After the insured pays out this amount, then the insurance company pays 100% costs for the covered services.