Originally published on Insurance.com.
Which health insurance plan is best for you?
The answer to that question really depends on a number of factors that pertain to your specific situation. When comparing health plan options, take these factors into account:
- Your health
- Your family’s health
- Your health care providers and whether they accept the insurance
- Your financial situation
- Whether you want to pay more upfront via premiums
- If you want flexibility and not having to ask for referrals to see a specialist
Once you review those factors, choosing a health plan is much easier.
The five most common types of health insurance plans are:
- Preferred provider organizations (PPOs)
- Health maintenance organizations (HMOs)
- High-deductible health plans (HDHPs)
- Point of service plans (POS)
- Exclusive provider organization plans (EPO)
The two most common health plans have been generally HMOs and PPOs, but HDHPs have become a lower-cost health insurance option for employers over the past decade. POS and EPO plans are options provided by some employers and health insurers, but they’re not nearly as common as HMOs, PPOs, and HDHPs.
In this guide, we provide information about each of these plans to help you make the right decision for your circumstances. We will go through each of the five plan types and highlight the differences.
What is a PPO?
PPO stands for preferred-provider organization. Premiums and deductibles are usually much higher for a PPO compared to an HMO, but that comes with greater flexibility.
About one-half of enrollees in employer-based health plans are in a PPO. Though it remains the most utilized type of plan, the number has been falling in recent years as employers turn more to HDHPs as a way to contain health care costs.
You usually don’t have to select a PCP in a PPO plan, and you can choose from more healthcare providers than an HMO because PPO networks are usually larger. PPOs allow you to get both in-network and out-of-network care — though out-of-network providers will be covered at a lesser percentage. You can also see a specialist without a referral.
Though a PPO gives you more independence, this doesn’t mean that you have complete access to the health care system without any oversight. A health plan may still require you and a physician to get approval for a costly service, such as an MRI.
In addition to higher premiums, PPOs usually have a deductible that you have to meet before the health plan pays for care.
Kaiser Family Foundation reports the average deductible for an individual PPO plan is $1,028. Once you’ve reached your deductible, your insurer begins to pick up its portion of the coinsurance.
The plans also include an out-of-pocket maximum for in-network care. If you reach your out-of-pocket maximum, all costs are covered by your insurer. A plan’s out-of-pocket maximum can vary widely, so you’ll need to check to see the out-of-pocket maximum for your plan. For Marketplace plans through Obamacare, the maximum out-of-pocket limits for 2017 are $7,150 for an individual plan and $14,300 for a family plan.
The main benefit of a PPO is flexibility, but it does come at the cost of higher premiums and a deductible that you will have to pay before your insurer starts paying for care.
When a PPO might be right for you:
- You want the flexibility to go out of network and not need to get referrals.
- Flexibility is more important to you than paying higher premiums.
- You would rather pay higher premiums, but likely pay less for the health care services.
What kind of person should opt for a PPO: Someone who utilizes health care regularly and sees specialists or wants to have the option to see a specialist without getting a referral.
What is an HMO?
HMO stands for health maintenance organization and makes up about 15 percent of health plans. It is known for its lower premiums and restricted network of doctors and hospitals, which means you sacrifice flexibility for lower upfront costs.
You’ll likely pay less in premiums for an HMO compared to a PPO – sometimes significantly less.
HMOs require that you name a primary care physician (PCP) who “coordinates” care, meaning your primary doctor must refer you first in order to see a specialist. HMOs usually don’t have deductibles (or they are lower than other plans). Instead, you pay copays for office visits, tests, and prescriptions.
One drawback to an HMO is that these plans usually don’t allow you to go outside your network for care. If you do, you’ll need to pay for the care on your own. An exception is if you need emergency care, which requires the facility (but not necessarily the providers) to bill as in network.
Not all providers accept HMOs, so before choosing an HMO, make sure your provider or providers accept the plan.
When an HMO might be right for you:
- You have a primary care physician and other providers who are in the HMO network.
- You don’t see many specialists and don’t need referrals often.
- You don’t mind the limitations of only seeing providers in your network.
- Cost is more important to you than flexibility.
What kind of person should opt for an HMO: Someone who wants to pay as little as possible in premiums though not have to face high deductibles. An HMO could be a good option if you have a PCP and your other health care providers are already in the HMO.
What is an HDHP?
HDHP stands for high-deductible health plan, which is also sometimes called a CDHP (consumer driven health plan). HDHPs have grown in popularity as more employers have begun offering the plans as a way to contain health care costs.
Nearly one-third of workers have an HDHP.
Unlike the other plans, an HDHP can vary depending on the specific plan. For instance, one HDHP could be very similar to an HMO, while another could look more like a PPO. The critical piece of an HDHP is the size of the deductible and Health Savings Account that is attached to it.
The deductible is usually higher in an HDHP compared to other plans. The IRS defines an HDHP as any plan with a deductible of at least $1,300 for an individual and $2,600 for a family. You need to pay that amount for care before your health insurance chips in.
The average HDHP deductible is a little more than $2,000, but one-fifth of HDHP plan enrollees have a deductible of more than $3,000, according to the Kaiser Family Foundation.
You’ll want to keep that in mind if you choose this plan, and you should set aside money for the deductible in case you need it.
HDHPs typically feature a Health Savings Account, which allows you to save money pre-tax to pay for qualified medical expenses. Some employers seed money in employee HSA accounts to help pay for care, so you’ll want to see if your employer provides money to employee HSAs when making a health plan decision.
Much like a PPO, your insurer will begin to pay its share of the coinsurance once you’ve reached your deductible. Your insurer will cover all costs once you’ve hit your out-of-pocket maximum.
HDHP usually have lower premiums so they can be a less costly plan option — as long as you don’t need a lot of medical care. HDHPs might be a good idea if you are young and healthy, but could be costly to older adults or young families.
Before deciding on an HDHP, think about your next year of potential health care costs to see whether the lower premiums will more than offset the potential costs of care.
When an HDHP might be right for you:
- You don’t have many health care costs, and you don’t expect to have many costs over the next year.
- You’d rather pay less upfront costs in premiums with the understanding that the higher deductible means you’ll pay more out-of-pocket if you need care.
- You don’t have children and/or a spouse on your plan who may use a lot of health care services.
What kind of person should opt for an HDHP: Someone who is healthy and doesn’t expect to use many health care services within the next year. You want the cheapest premiums and don’t mind having to pay a high deductible if you need a lot of care.
What is a POS?
POS stands for point of service plan and makes up about 10 percent of health plans. POS plans are not nearly as common as PPOs, HDHPs, and HMOs. POS plans are a hybrid of PPO and HMOs. In fact, point of service means that the health care consumer gets to choose whether to use HMO or PPO services each time you see a provider.
POS plans usually have similar rules to HMOs (for instance, you need to choose an in-network physician as your PCP), but you can see an out-of-network physician for a higher fee in a POS plan.
When a POS might be right for you:
- You have a PCP in the POS plan.
- You want the flexibility of going out of network like a PPO — and don’t mind paying the higher out-of-pocket fees when you need to go out of network.
- You’re good at keeping health care receipts. You don’t mind filling out forms and sending in bills for payment if you get care out of network.
What kind of person should opt for a POS: Someone who likes being able to go out of network for care, but also wants a PCP coordinating your care.
What is an EPO?
EPO stands for exclusive provider organization and is a managed care plan that requires you to go to doctors and hospitals in the plan’s network.
You don’t need to choose a PCP or need a referral, so in that sense, it’s similar to a PPO, but you will only receive coverage for providers in your network. Other parts of an EPO plan are similar to an HMO, such as having a limited network of doctors and hospitals. You can’t get care outside the network unless it’s an emergency.
Much like a PPO, you need to get approval from your health plan in order to get what’s deemed as an expensive service.
When an EPO might be right for you:
- You want the flexibility of a PPO and don’t need a referral as long as you stay in-network.
- You’re OK having a limited network of doctors and facilities like an HMO.
- You want a network like an HMO, but don’t want to choose a PCP.
What kind of person should opt for an EPO: Someone who doesn’t mind have a limited number of doctors and facilities and would rather not have to get a referral to see a specialist.
What is the difference between HMO, PPO, HDHP, POS and EPO?
It’s open enrollment season at your job and your employer offers you a choice between the three biggest plan types: HMO, PPO, and HDHP. Which is best? It really depends on your financial and medical situation – and preferences.
For instance, would you rather the flexibility of not having to go to a smaller group of providers in an HMO and don’t mind paying more upfront for your care via premiums? Then, a PPO might be right for you.
Do you not care about having a large network of providers, but paying as little as possible for health care is more important to you? Then, an HMO could be perfect.
Do you not use medical services often and you want a plan that will protect you, but not cost much in terms of upfront premiums? Then, an HDHP could be the direction to go.
Choosing the right health insurance plan is a personal decision and depends on your situation and preferences. Whether you ultimately choose a PPO, HMO, HDHP, POS or EPO, take costs, flexibility, coverage and convenience into account when making that decision.
| Type of plan | Average deductible* | Require PCP? | Need referrals? | Out of network care |
|---|---|---|---|---|
| HMO | $917 | Yes | Yes | No |
| PPO | $1,028 | No | No | Yes |
| HDHP | $2,199 | Varies | Varies | Varies |
| POS | $1,737 | No | No | Yes, but costlier |
| EPO | NA | No | No | No |
*Kaiser Family Foundation, 2016 Employer Health Benefits Survey. Note: The survey did not include the average deductible amount for an EPO.
Masterson Media 