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Types of Health Insurance
Understanding the Types of Health Insurance Options Available
September 19, 2024 | 6 min read
In 2021, the average cost of just one night in a U.S. hospital was nearly $3,000. Today, that price is probably higher, which means unexpected healthcare needs could end up costing hundreds of thousands of dollars. That’s why it’s important to have health insurance and to understand your healthcare benefits.
I’m Healthy. Do I Really Need Health Insurance?
While healthy people are generally less likely to need to visit their doctors, accidents that require medical care can happen to anyone at any time. So it’s best to be prepared. Fortunately, there are many types of health insurance options available to provide the healthcare benefits you need.
What Are the Different Types of Health Insurance?
There are several types of health insurance plans to help pay for your care. These include:
- Exclusive Provider Organizations (EPOs)
- Health Maintenance Organizations (HMOs)
- Preferred Provider Organizations (PPOs)
- Point-of-Service (POS) Plans
Whether you are covered on a spouse or a parent’s plan, or you select your insurance yourself from an employer or the Health Insurance Marketplace, it’s important to understand the differences between these types of plans.
What is an EPO plan?
An EPO is an exclusive provider organization. As the name suggests, EPO plans only cover healthcare services provided by doctors, specialists or hospitals within the plan’s contracted network. Except in an emergency, EPO plans do not usually cover out-of-network care.
Pro Tips
Typically, you can seek care from anyone in the network, including specialists, without a referral. Except in the case of an emergency, avoid out-of-network providers and facilities.
What is an HMO plan?
An HMO is a health maintenance organization. Generally, with an HMO plan, members select a primary care physician (PCP) from among a local network of providers. Then, whenever you have a healthcare need – except in an emergency – you will visit your PCP. If specialized care is needed, your PCP will then refer you to the appropriate specialist within the HMO’s network. This way, the PCP can stay informed about your health and more fully coordinate your overall care.
Pro Tips
If you already have a PCP, you may want to check if your provider is part of the HMO before selecting this type of plan.
Except in the case of an emergency, avoid out-of-network providers and facilities.
If you need to see a specialist, referrals from your PCP are required.
What is a PPO plan?
A PPO is a preferred provider organization. This means that you can pay less if you receive care from within the large network of preferred providers. But you can also use providers outside the network. However, coverage for out-of-network services is less, so you will have to pay more out of your own pocket if you see a doctor outside the PPO network.
Pro Tips
Choosing a PCP is not required. But if you already have one that you want to continue seeing, you may want to check if the provider is part of the PPO.
You may see out-of-network providers, but you will have to pay more compared to similar in-network providers.
Referrals are not required.
What is a POS plan?
A POS, or point of service, plan allows you pay to less if you use doctors, hospitals and other healthcare providers that that are within the plan’s network. However, you can use providers outside the network, but it will cost more out of your pocket. If you need to see a specialist, POS plans require that you get a referral from your primary care physician.
Pro Tips
If you already have a PCP, you may want to check if your provider is part of the POS network before selecting this type of plan.
You may see out-of-network providers, but you will have to pay more compared to similar in-network providers.
If you need to see a specialist, referrals are required.
| EPO | HMO | PPO | POS | |
|---|---|---|---|---|
| Primary care provider (PCP) required? | No | Yes | No | No |
| Referrals required? | Usually, you can see any provider in your network without a referral. | Yes | No | Yes |
| Out-of-network coverage | Generally covered only for medical emergencies | Generally covered only for medical emergencies | Yes, but you will likely pay more compared to in-network providers | Yes, but you will likely pay more compared to in-network providers |
Depending on which state you live in, you may be able to find all of these types of plans on the Health Insurance Marketplace. As you shop for plans, you’ll want to consider the type of insurance as well as the details about the benefits and coverage, including premiums, deductibles, copays, coinsurance and out-of-pocket costs. Some Marketplace plans may even include dental and vision coverage.
Shop for health insurance plans from Ambetter Health now or call us at 844-933-0380 (TTY: 711) from 8 a.m. to 9 p.m. ET. to learn more about your health insurance options. Our licensed agents can help you find the right plan for your unique needs.
Questions About Types of Health Insurance
When you shop for healthcare plans, the type will be listed near the plan name. Look for EPO, HMO, PPO and POS. And if you click to look at a plan’s “Summary of Benefits and Coverage,” the plan type should be noted there as well.
A network is a group of providers who have contracted to offer healthcare benefits or services to the plan’s members at prices that the provider and the plan agreed on.
Some plans will not cover any services provided by anyone outside the network, so you would have to pay the full cost. Other plans will allow you to use providers outside the network, but the amount you have to pay will be more compared to services from in-network options.
When you shop for plans in your state, look for each plan’s “plan details.” In this section, you should find a link to a provider directory, where you can search by physician name, area of specialty (such as primary care provider, orthopedics, etc.), location, etc. If the “In Network” section has a check mark, that person or facility is in this plan’s network.
If you have a true emergency and need to seek help right away, your plan can’t make you pay more in copayments or coinsurance if your care is from an out-of-network hospital. They also can’t make you get prior approval before getting emergency care outside your plan’s network.
Learn more about health insurance coverage for emergency services.
Find the right Ambetter Health plan to fit your needs. Shop our plans or call our licensed agents at 844-933-0380 (TTY: 711) from 8 a.m. to 9 p.m. ET.
Shop Ambetter Health Plans
Find a health insurance plan with the right out-of-pocket max to meet your needs.
Or call our helpful team:
844-933-0380 (TTY: 711)
8 a.m. to 9 p.m. ET
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