An overview of the different health insurance network types, types of Marketplace plans, and how to choose a health insurance network.
There are different types of Marketplace health insurance plans designed to meet different needs. Some health insurance network types restrict your provider choices or encourage you to get care from the plan’s network of doctors, hospitals, pharmacies, and other medical service providers. Others pay a greater share of costs for providers outside the plan’s network.
So what’s the best health plan network? That depends on your needs.
Today we’ll look at the different health insurance network types, types of Marketplace plans, and how to choose a health insurance network.
Types of Marketplace Health Insurance Plans
Depending on how many health insurance plans are offered in your area, you may find plans of all or any of these types at each metal level – Bronze, Silver, Gold, and Platinum. Within those, there are 4 major health insurance network types:
EPO Health Plans
HMO Health Plans
POS Health Plans
PPO Health Plans
Below are some examples of types of Marketplace plans to help you pick the best health plan network for your needs.
Exclusive Provider Organization (EPO) Health Plans
An EPO health plan is a managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s EPO network (except in an emergency).
What are the Pros of EPOs?
No referral to see a specialist, saving you the cost of a copayment and time to see your primary care physician.
Having a primary care physician is optional.
Emergency care is covered even if you go out of your network.
EPO health plans generally cost you less in premiums and out-of-pocket costs.
Your in-network providers (EPO network) will file claims for you.
Some EPO health plans have broad, national networks, so you may have access to an in-network doctor when you travel.
What are the Cons of EPOs?
You may not be able to continue with your current doctor or specialists.
You must use in-network providers from the EPO network unless it’s an emergency.
For EPO health plans with local networks only, non-emergency medical needs will not be covered when you travel.
Even if your insurer covers out-of-network emergencies, the provider can still bill you for the difference between its charges and your insurer’s payments.
You are responsible for staying in your network.
You are responsible for obtaining prior approval for expensive services and tests.
Health Maintenance Organization (HMO) Health Plans
An HMO health plan is a type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO network. It generally won’t cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
Usually cheaper than the same coverage using Original Medicare.
Privately run companies.
Billing is often more streamlined and easier to understand.
Many health insurance plans to choose from so you can get the best plan for your needs.
Often includes some coverage not covered under Original Medicare. Things like dental and vision care are often offered by HMO health plans but are not covered under Original Medicare.
Includes an agent who can explain changes in rules and plan alternatives.
Uses a network (HMO network) where most providers know each other. This makes it easier to coordinate care, keeps expenses low, and prevents unnecessary treatment.
Primary care physician who will get to know your case file and who can help you with specialists.
The appeals process includes an additional level of appeals.
HMO Medicare Plans are usually location specific. This means that if you need to see a provider out of the network and it isn’t an emergency the plan will likely only cover a small portion of the bill. This can be very difficult for older people who have seen a particular specialist for years and have no desire to change. If the specialist isn’t included within the provider network the patient must either pay more out of pocket or use a different provider. This is also a huge disadvantage for seniors that spend part of the year in a different location. If you are out of the network everything from your doctor’s bills, to your eye checkup, to your prescription refill may not be covered. This is a serious disadvantage and something to think about because almost any provider can be used with Original Medicare.
To see a specialist you will need to first get a referral from your primary care physician. For many seniors, and especially for those with mobility issues, this is a huge inconvenience.
A Medicare HMO health plan can’t be used with Supplemental Insurance. Supplemental Insurance from a previous employer or another insurance company cannot be used with a Medicare HMO Plan. For patients with very serious medical problems, supplemental insurance can be a huge help. It generally pays all of the patient’s costs of care. Supplemental insurance also extends hospitalization coverage and can include extras like travel insurance.
The use of Network providers is needed to keep out-of-pocket expenses low.
Point of Service (POS) Health Plans
A POS health plan is a type of plan where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s POS network. POS plans require you to get a referral from your primary care doctor in order to see a specialist.
POS health insurance is essentially a hybrid of a health management organization (HMO) and preferred provider organization (PPO). With POS health plans, members have the freedom to visit physicians that are out-of-network which allows ample opportunity to receive the medical attention they need with a provider they are comfortable with.
As POS health plans are similar to an HMO with out-of-network benefits, members can see any specialist. This flexibility can be highly useful for certain people, such as members who frequently use outpatient medical services, such as physical therapy or counseling.
Other major advantages of choosing POS health insurance from an insurance broker are the low co-pays and zero deductibles. With a POS health plan, you will typically have no deductible and the co-payments often range from $10 to $20 for regular office visits with in-network medical providers or facilities.
On average, premium costs of a POS health insurance policy are nearly one-half of the costs associated with PPO health plans. Without a deductible, any out-of-pocket costs are also lowered. The breakdown of cost under a POS health plan is similar to other types of managed plans but typically less costly than PPO.
Coverage flexibility is one of the biggest perks of having POS health insurance. POS plans often offer a better combination of in-network and out-of-network benefits than other options (like HMO health plans). While you can expect to pay higher out-of-network fees compared to in-network fees, members have wider access to health providers and specialists.
POS health insurance benefits are also not limited to local healthcare providers. Unlike PPO health plans that restrict benefits to in-network providers within a certain coverage territory or state, POS health plans do not have these local restrictions.
While POS health insurance can be highly beneficial to some individuals, it may not be as favorable to others. As one of the biggest advantages of POS health plans are the ability to see a broad range of healthcare specialists, individuals who rarely or never need to see a specialist may not get as much value from this plan.
Most POS health plans also require a referral from your primary care physician. Many people find the process of getting a referral complex and time-consuming. For this reason, some individuals may prefer a plan like PPO which allows you to see any in-network healthcare provider, including specialists, without a referral.
Another major downfall of POS health insurance is the amount of paperwork that members often face. If a member chooses to see an out-of-network healthcare provider, they will have to pay the provider’s fees upfront, which is not always possible due to financial restraints.
The member must then file a claim for reimbursement and wait for a decision from the insurance company. If you fail to get a referral from your primary care provider your services may not be covered or be only partially covered. The cost of out-of-network providers can also be high.
Members can expect to pay upwards of 30% — 40% of the bill out-of-pocket.
Preferred Provider Organization (PPO) Health Plans
A PPO health plan is a type of health plan where you pay less if you use providers in the plan’s PPO network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.
PPO health plans do not require you to select a Primary Care Physician.
You can choose any doctor you like, but PPO health plans offer discounts to those within their preferred network.
No referral is required to see a specialist with a PPO health plan.
There is more flexibility than other health insurance network types.
You have greater control over your choices as long as you don’t mind paying for them.
PPO health plans have a higher monthly premium than other health insurance networks.
You will have higher out-of-pocket expenses.
You must monitor in-network vs out-of-network to control costs.
Help Choosing a Health Insurance Plan
If you are unsure about which type of health insurance plans are best for your needs, or you need help picking the best health plan network for your needs, Cover Kansas can help! We offer FREE services to help all Kansas residents with choosing health insurance plans in the marketplace.
Cover Kansas Navigators are trained, unbiased individuals that can help you compare health insurance plans, assist you with the online application process, and provide answers to your Marketplace questions year-round.
We understand that getting coverage through the federal Health Insurance Marketplace can be a complicated process. That’s why we simplified it! Check out our website to find answers to any questions you might have about enrolling and get free assistance from a certified Navigator.