Health Plan Cheat Sheet

With open enrollment right around the corner, it’s important to understand exactly what your insurance options are, and which one is best for you and your family. Use our Health Plan Cheat Sheet to educate yourself on each type of plan so you can feel confident when shopping for health insurance this year.

HEALTH MAINTENANCE ORGANIZATION (HMO)

Features

Costs

Pros and Cons

  • Health-care providers contract with insurance carriers to create a provider network
  • Providers agree to accept predetermined fees for service
  • Members choose a primary care physician (PCP) from a list of participating doctors
  • PCP provides care, makes referrals
  • Flat fee or co-payment for in-network services regardless of service cost
  • No Deductible
  • Minimal paperwork no claim forms
  • Preventive care incentives
  • Generally good for families and individuals focused on routine care and predictable expenses
  • Referral from PCP required to see a medical specialist.
  • Providers from within network only
  • Predetermined care guidelines.

 

PREFERRED PROVIDER ORGANIZATION (PPO)

Features

Costs

Pros and Cons

  • Health-care providers contract with employers, insurance plans, or other third-party administrators to provide comprehensive medical service
  • Payment received when care is given
  • Members not restricted to in-network options.
  • No PCP selection
  • Out-of-pocket yearly deductible
  • Co-Insurance fee for in-network services
  • Deductibles and co-insurance fee for out-of-network services.
  • Flexibility of in-network and out-of-network options.
  • No PCP or referrals required.
  • Often has a lifetime maximum benefit limit.

 

POINT OF SERVICE PLAN (POS)

Features

Costs

Pros and Cons

  • The plan is based on an HMO formant.
  • Members choose a PCP from a list of participating doctors.
  • Chosen doctor from in-network selection serves as “point of service’ and makes referrals
  • Allows option out of the network at a reduced benefit without PCP referral
  • Co-insurance fee for in-network office and hospital visits
  • Out-of-pocket yearly deductible
  • Deductible and co-insurance fees for out of-of-network services
  • Flexibility of in-network and out-of-network options
  • Benefits of both an HMO and a full health insurance indemnity plan
  • Usually higher out-of-network costs if self-referred
  • Paperwork claims for reimbursement

 

EXCLUSIVE PROVIDER ORGANIZATION (EPO)

Features

Costs

Pros and Cons

  • Plan resembles an HMO
  • Members may be required to choose a PCP from an exclusive list of participating providers
  • PCP provides  care, makes referrals
  • Very restricted network
  • Lower rates than most plans because of exclusive in-network service only
  • Flat fee or co-payment for in-network services regardless of service cost
  • Monthly premium and deductible
  • Minimal paperwork. No claim forms.
  • Restrictive provider selection and credentialing process.
  • Enrollees required to receive care form their participating provider.

 

HIGH-DEDUCTIBLE HEALTH PLAN (HDHP)

Features

Costs

Pros and Cons

  • Unlike a traditional health plan
  • Participation in a HDHP is a requirement for having a health savings account (HSA)
  • A form of catastrophic coverage.
  • Some HDHP plans also offer additional “wellness” benefits
  • Plan with lower premiums and higher deductibles
  • HDHPs have higher annual out-of-pocket limits than many plans
  • Out-of-pocket expenses include co-payments and other amounts, but do not include premiums
  • Offers individuals an option of making lower monthly payments.
  • A higher annual deductible than a typical health insurance plan
  • With the exception of preventive care, the annual deductible must be met before plan benefits are paid.