Type of Health Insurance Plan in US
Type of Health Insurance Plan in US

Types of Health Insurance Plans

There are many types of health insurance plans, including:

  • Individual health insurance: This plan provides medical coverage for the policyholder. 
  • Family floater plan: Also known as family health insurance, this plan covers the entire family under one plan. 
  • Medicare: A public health insurance program for people who are 65 or older. Patients pay premiums and deductibles for their medical costs. 
  • Medicaid: A federal program that provides affordable health insurance coverage for low-income families or people with certain disabilities. 
  • Senior citizen plan: This plan covers medical expenses for adults over 60 years old. It also provides preventative health check-ups and cashless treatment at network hospitals. 
  • Health insurance plans from the Health Insurance Marketplace: These plans come in different coverage levels, including Bronze, Silver, Gold, or Platinum. 
  • High-deductible health plans: These plans can include a Health Savings Account (HSA), which has tax advantages. 

When choosing a health insurance plan, you can consider things like:

Waiting period: The policy only comes into effect after the initial waiting period is over.
Co-payment: A percentage of the claim amount may need to be paid by the policyholder.
Claim settlement: There are two types of claim settlement: cashless and reimbursement.

Health Insurance Plans

Each insurance brand may offer one or more of these four common types of plans:

  • Health maintenance organizations (HMOs)
  • Preferred provider organizations (PPOs)
  • Exclusive provider organizations (EPOs)
  • Point-of-service (POS) plans
  • High-deductible health plans (HDHPs), which may be linked to health savings accounts (HSAs)

An HMO delivers all health services through a network of healthcare providers and facilities. With an HMO, you may have:

  • The least freedom to choose your health care providers
  • The least amount of paperwork compared to other plans
  • A primary care doctor to manage your care and refer you to specialists when you need one so the care is covered by the health plan; most HMOs will require a referral before you can see a specialist.
What doctors you can see. Any in your HMO’s network. If you see a doctor who is not in the network, you may have to pay the full bill yourself. Emergency services at an out-of-network hospital must be covered at in-network rates, but non-participating doctors who treat you in the hospital can bill you.What you pay:

  • Premium: This is the cost you pay each month for insurance.
  • Deductible: Your plan may require you to pay the amount before it covers care except for preventive care.
  • Copays and/or co-insurance for each type of care. A copay is a flat fee, such as $15, that you pay when you get care. Coinsurance is when you pay a percentage of the charges for care, for example, 20%. These charges vary according to your plan and they are counted toward your deductible.

Paperwork involved. There are no claim forms to fill out.

With a PPO, you may have:

  •  A moderate amount of freedom to choose your health care providers — more than an HMO; you do not have to get a referral from a primary care doctor to see a specialist.
  • Higher out-of-pocket costs if you see out-of-network doctors vs. in-network providers
  • More paperwork than with other plans if you see out-of-network providers
What doctors you can see. Any in the PPO’s network; you can see out-of-network doctors, but you’ll pay more.What you pay:

  • Premium: This is the cost you pay each month for insurance.
  • Deductible: Some PPOs may have a deductible. You may have a separate, higher deductible if you see an out-of-network doctor.
  • Copay or coinsurance: A copay is a flat fee, such as $15, that you pay when you get care. Coinsurance is when you pay a percentage of the charges for care, for example, 20%.
  • Other costs: If your out-of-network doctor charges more than others in the area do, you may have to pay the balance after your insurance pays its share.

Paperwork involved. There’s little to no paperwork with a PPO if you see an in-network doctor. If you use an out-of-network provider, you’ll have to pay the provider. Then you have to file a claim to get the PPO plan to pay you back.

With an EPO, you may have:

  • A moderate amount of freedom to choose your health care providers — more than an HMO; you do not have to get a referral from a primary care doctor to see a specialist.
  • No coverage for out-of-network providers; if you see a provider that is not in your plan’s network – other than in an emergency – you will have to pay the full cost yourself.
  • Lower premium than a PPO offered by the same insurer

What doctors you can see. Any in the EPO’s network; there is no coverage for out-of-network providers.

  • Premium: This is the cost you pay each month for insurance.
  • Deductible: Some EPOs may have a deductible.
  • Copay or coinsurance: A copay is a flat fee, such as $15, that you pay when you get care. Coinsurance is when you pay a percentage of the charges for care, for example, 20%.
  • Other costs: If you see an out-of-network provider you will have to pay the full bill.

Paperwork involved. There’s little to no paperwork with an EPO.

A POS plan blends the features of an HMO with a PPO. With POS plan, you may have:

  • More freedom to choose your health care providers than you would in an HMO
  • A moderate amount of paperwork if you see out-of-network providers
  • A primary care doctor who coordinates your care and who refers you to specialists

What doctors you can see. You can see in-network providers your primary care doctor refers you to. You can see out-of-network doctors, but you’ll pay more.

What you pay:

  • Premium: This is the cost you pay each month for insurance.
  • Deductible: Your plan may require you to pay the amount of a deductible before it covers care beyond preventive services. You may pay a higher deductible if you see an out-of-network provider.
  • Copays or coinsurance: You will pay either a copay, such as $15, when you get care or coinsurance, which is a percent of the charges for care. Copayments and coinsurance are higher when you use an out-of-network doctor.

Paperwork involved. If you go out-of-network, you have to pay your medical bill. Then you submit a claim to your POS plan to pay you back.

If you are under the age of 30 you can purchase a catastrophic health plan. With a catastrophic health plan you may have:

  • Lower premium
  • 3 primary care visits before the deductible applies
  • Free preventive care, even if you haven’t met the deductible

What doctors you can see. Any in the plan’s network; individual plans may have additional rules on specialists.

What you pay:

  • Premium: This is the cost you pay each month for insurance.
  • Deductible: A catastrophic health plan has a deductible of $9,450 for an individual and $18,900 for a family in 2024. After you reach that deductible, the plan will pay 100% of your medical costs for covered benefits.

Paperwork involved. You will want to keep track of your medical expenses to show you have met the deductible.

Similar to a catastrophic plan, you may be able to pay less for your insurance with a high-deductible health plan (HDHP). With an HDHP, you may have:

  • One of these types of health plans: HMO, PPO, EPO, or POS
  • Higher out-of-pocket costs than many types of plans; like other plans, if you reach the maximum out-of-pocket amount, the plan pays 100% of your care.
  • A health savings account (HSA) to help pay for your care; the money you put in an HSA is not taxed and can be used tax-free on eligible medical expenses. In order to have an HSA, you must be enrolled in an HDHP.
  • Many bronze plans may qualify as HDHPs depending on the deductible (see below).
What doctors you can see. This varies depending on the type of plan — HMO, POS, EPO, or PPOWhat you pay:

  • Premium: An HDHP generally has a lower premium compared to other plans.
  • Deductible: The deductible is at least $1,500 for an individual or $3,000 for a family, but not more than $8,050 for an individual and $16,100 for a family in 2024. Like with all plans, your preventive care is free even if you haven’t met the deductible.
  • Copays or coinsurance:  Other than preventive care, you must pay all your costs up to your deductible when you go for medical care. You can use money in your HSA to pay these costs.
You can set up a Health Savings Account to help pay for your costs. The maximum you can contribute to an HSA in 2024 is $4,150 for individuals and $8,300 for families. You can contribute an additional $1,000 if you are 55 or older.Paperwork involved. Keep all your receipts so you can withdraw money from your HSA and know when you’ve met your deductible.
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