Health insurance will cover medical expenses due to an injury or illness. An individual policy is a plan that you select to provide protection in the event that a health condition occurs.
Choosing the right health insurance plan can be a challenge. There are so many choices to make and questions to answer and many are not easy to understand.
▪ Can you select the type of plan with your employer? or is it required that you go through the state or federal marketplace? ▪ If so, what is the best option for you and your family? an HMO, PPO, EPO or a POS? ▪ What out of pocket costs are associated with the services or treatments that your health insurance plans cover?
The majority of individuals receive their health insurance through an employer. Others, purchase the insurance through the government marketplace which is an affiliation of the Affordable Care Act. Then there are some others that find insurance coverage by going directly outside the marketplace to the insurer.
If you are able to receive health insurance coverage through an employer, it would be the cheapest or best possible option for these reasons.
Employer health plans usually provide much lower premiums and an employer will often pay part of the employees premium
The biggest issue with an employer based health insurance is the fact that in most scenarios, it does not allow the employee to select the plan type. If you are not concerned about if you have a PPO or HMO as a plan, then this is fine, however, it can be a big deal if your preference is for a particular plan over another.
Buy health coverage through a state of federal marketplace if you are unable to purchase it through an employer might be the next best option. But if the coverage from an employer is overly expensive, you might still want to consider the marketplace.
Purchasing health insurance other than the marketplace
The other option would be to buy health insurance directly through an insurer is for those that don’t want to receive coverage from a government marketplace.
Health insurance plans such as “off marketplace” can be purchased from:
▪ Insurance brokers or agents ▪ Health insurance companies ▪ Health insurance online sellers
The “off market” health plan is a good idea in some circumstances, but the premium night be a lot higher than if you were buying it through a state or federal marketplace. Reason being is that you might qualify for savings based on your earnings or premium tax credits with the marketplace.
If you receive your health insurance plan through an employer or directly from an insurer or marketplace, you will often be able to select a specific type of plan.
▪ Preferred Provider Organization (PPO) ▪ Health Maintenance Organization (HMO) ▪ Point of Service (POS)
A health insurance plan which provides a little more leverage than a HMO would be a PPO.
A PPO plan will encourage you to use a provider within the network, but unlike an HMO, a PPO is a lot more flexible with regards to your options for receiving out of network care.
You might receive a reimbursement through your insurer for 80% of in network costs. But out of network costs of only 60% if your plan is a PPO.
If you have the option, another good reason to look into a PPO plan vs an HMO is the fact that a PPO will very rarely require a referral regardless of if you go outside of your plans network or stay inside.
The HMO option will limit coverage to the care provided by hospitals, labs and physicians and others that are within network.
Typically you will be responsible if buying unauthorized or care out of the network. You would be required to receive a referral from your primary care doctor for any specialist treatment.
Therefore, why would you want to select an HMO over a PPO policy? The cost you are required to pay out of pocket that are associated with an HMO are often much lower as long as you remain within the network.
The monthly premium is the main cost that you will be responsible for with an HMO. Outside that and a deductible, there will only be a small co-pay if and when you visit your physician or seek any other medical assistance.
A POS plan is a combination of a HMO and a PPO. The POS plan is similar to a HMO in that they usually give you the option to choose your in network physician that will become your primary care provider. You will also be required to receive a referral in order to see a specialist.
Therefore POS plans are very similar to the PPO since they allow you to receive treatments and care outside of the network. If you decide to use an in network physician, lab or hospital you will most likely pay less.
Determining just how much you will need to pay out of pocket will be just as important as selecting a health insurance plan.
If you focus on these parts of a health plan, it will help you in making a decision of lot sooner.
▪ Co-pay ▪ Co-insurance ▪ Deductible ▪ Premium
Copay and co-insurance costs are often tied to out of pocket maximums. Therefore, with certain plans you will be required to pay co-insurance costs until a certain amount is reached.
Before deciding on a health plan it would be suggested that you look into at the policy’s co-insurance and co-pay if you have that option.
You should also review the deductibles and premiums that are part of the health plan. It is not a good idea to simply focus on plans with the lowest deductible or premiums. The plans with lower cost premiums often have a higher deductible. Also, plans with lower deductibles typically have a higher premium.
In terms of benefits, treatment and services, it is a good idea to look at what these plan options do and don’t cover.
The majority of health insurance plans help with payment for prescription drugs. There are some medications that are not covered by some health plans, marketplace or employer based plan policy’s. Similarly, they may not cover them to the same extent. Therefore, you need to be sure that the plan will cover the medications or drugs you take.
A wider range of health plans cover preventative care now as well. Examples are, screenings, lab tests, immunizations, etc.
You need to make certain that the plan you are deciding on covers preventative care if it is important to you and be certain that the plan covers as much as possible.
While you research a health insurance plan’s coverage and benefits, you should pay particular attention to these treatments and service options:
▪ Fertility treatments ▪ Chiropractic or Acupuncture treatments ▪ Weight loss management ▪ Physical therapy ▪ Mental health services