How To Choose A Health Insurance Plan

Comparing Types of Health Insurance Plans

Health insurance can vary in cost, coverage, and access to doctors and specialists depending on the plan you choose. Understanding how to select health insurance requires familiarity with the different types of plans.

• Health Maintenance Organization (HMO): HMOs limit coverage to select care providers in the plan’s network and sometimes require a referral from your primary care provider (PCP) to see a specialist. If you choose to see a doctor outside of the plan’s network or without a referral, you may be responsible for the entire cost for care, unless it’s a medical emergency. Many Anthem HMO plans, however, do not require you to see your PCP for a referral to a specialist.

• Preferred Provider Organization (PPO): PPOs offer a “preferred” network of care providers and do not require a PCP referral to see a specialist. If you choose to see a doctor outside of the plan’s network, you’ll typically be responsible for a larger part of the cost for care.

• Exclusive Provider Organization (EPO): An EPO is a hybrid of an HMO and a PPO. EPOs generally offer more flexibility than an HMO and usually cost less than a PPO. Like a PPO, you won’t need a referral to get care from a specialist. But similar to an HMO, you’ll be responsible for paying the costs for seeing a care provider outside of the plan’s network.

Compare HMOs, PPOs, and EPOs:

• HMO: Lowest premium—Highest out-of-pocket costs for out-of-network care
  • Only in-network care providers and emergency visits are covered
  • Select care provider options
  • Referrals may be needed to see specialists

• PPO: Higher premium—Lower out-of-pocket costs for in-network care
  • Out-of-network care providers are accepted, but cost more
  • More care provider options
  • No referrals needed to see specialists

• EPO : Lower premium—Higher out-of-pocket costs for out-of-network care
  • Only in-network care providers and emergency visits are covered
  • Select care provider options
  • No referrals needed for specialists

Understanding Health Plan Networks and Insurance Costs

As you explore how to choose a health insurance plan, it’s important to review and compare a plan’s network, premium, and out-of-pocket costs for care.

• Network: A network is made up of doctors, other healthcare professionals, hospitals, and pharmacies that an insurer contracts with to provide care. Typically, using “in-network” care providers results in lower out-of-pocket costs for you — so finding a plan with a network that meets your care needs is an important part of managing health insurance costs.

• Premium: A plan premium is your monthly payment for health insurance coverage. Typically, the more coverage you have, the higher your premium will be.

• Out-of-pocket costs: Out-of-pocket costs include your plan deductible, coinsurance, and copays for care. Out-of-pocket costs are usually more when you see an out-of-network care provider.

As you consider health insurance and how it could fit into your overall budget, check if you are eligible for financial help, also known as a health insurance subsidy.  Health insurance subsidies from the government can help lower or eliminate your monthly premium. Additionally, cost-sharing reductions are available for those who enroll in a Silver plan and meet the eligibility requirements for income and household size. Cost-sharing reductions can provide extra savings on out-of-pocket costs including your deductible, copays, coinsurance, and out-of-pocket maximum. 

Comparing Health Insurance Benefits

All ACA plans include coverage for essential health insurance benefits such as preventive care (vaccinations, annual physicals, and health screenings), emergency care and hospitalization, doctor visits, mental health services, and prescription medications. Specific benefits can vary depending on the type of plan and the insurer. When choosing medical insurance, take time to determine the benefits you and your family may need and use most.

Ask yourself these questions to help narrow down the type of plan that may work best for you.

• If you currently have a preferred PCP, is that doctor included in your potential plan’s network?

• Do you mind seeking referrals from your PCP for specialist visits?

• Are the prescription drugs you use regularly covered by the plan you’re considering?

While looking at your health insurance options, you may also want to consider dental and vision coverage. Some Marketplace health plans include dental or vision benefits for children and some plans may provide coverage for adults.

If the medical plan you select does not include dental or vision coverage, Anthem offers stand-alone dental and vision plan options for whole health protection.

Need Help Navigating Marketplace Plans?

Anthem is here to assist you compare Marketplace plans, including their costs and networks, to help you find health insurance that fits your needs and budget.