What are four individual health insurance policies that are regulated by individual states

What are Health Maintenance Organizations (HMOs)?

HMOs give you a local network of participating doctors, hospitals, and other health care professionals and facilities that you are required to choose from. These types of health insurance plans also require you to choose a Primary Care Provider (PCP) from the network. Your PCP is your home base for medical care. They get to know you and help coordinate all your care. They will also need to provide you with a referral to see in-network specialists. The costs for an HMO plan—copays and coinsurance—are typically lower than other types of health plans, as long as you stay in-network.

What are Exclusive Provider Organizations (EPOs)?

EPOs offer you a network of participating providers to choose from. Most EPO plans do not include coverage for out-of-network care except in the case of an emergency. This means that if you visit a provider or facility outside the plan’s local network, you will likely have to pay the full cost of services yourself.

Depending on the plan, you may or may not be required to choose a Primary Care Provider (PCP). If you want to see a specialist in your network, you don’t need a referral from a PCP.

What is a Point-of-Service (POS) Plan?

POS plans combine features of HMO and PPO plans. The provider network is typically smaller than a PPO plan and the costs for in-network care are typically lower, like an HMO. POS plans also require you to choose a Primary Care Provider (PCP) from within the plan’s network of doctors and other primary care professionals. Your PCP is your home base for care and advice. They get to know you and your health needs and can help coordinate all your care.

If you need to see a specialist, you are required to get a referral. However, like a PPO, you can also choose to see specialists that are in-network or out-of-network. If you see a doctor outside the plan’s network, your share of the costs will be higher and you’ll be responsible for filing any claims yourself.

What are Preferred Provider Organizations (PPOs)?

PPOs typically offer you a large network of participating providers so you have a lot of doctors, hospitals, and other health care professionals and facilities to choose from. You may also choose to see providers from outside of the plan’s network, but you will pay more out-of-pocket.

Choosing a Primary Care Provider (PCP) is not required with these types of health plans, and you can see specialists without a referral.

What types of health insurance are best for me?

Start by understanding your specific health care needs:

• If you’re in good health and don’t visit a doctor often,health insurance plans with higher deductibles typically have lower insurance premiums and could help save you money.
• If you require or expect more than just preventive care,consider plans that have lower deductibles and coinsurance, for more predictable costs.

I have a chronic condition. What types of health insurance are best for me?

Chronic conditions could require regular medication and more frequent doctor appointments, even costly hospital stays and/or surgeries. Consider a health plan that helps minimize out-of-pocket costs based on what you anticipate for doctor care, specialist visits, prescription medications, etc.

A little bit of time spent planning will help you in choosing the right types of health insurance.

There are different types of Marketplace health insurance plans designed to meet different needs. Some types of plans 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.

Types of Marketplace plans

Depending on how many 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.

Some examples of plan types you’ll find in the Marketplace:

• Exclusive Provider Organization (EPO): A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency).

• Health Maintenance Organization (HMO): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. 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.

• Point of Service (POS): A type of plan where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans require you to get a referral from your primary care doctor in order to see a specialist.

• Preferred Provider Organization (PPO): A type of health plan where you pay less if you use providers in the plan’s network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.

Get more information on what you should know about provider networks (PDF).

Need dental coverage? Visit our Dental coverage in the Marketplace page to learn more about options available to you.

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