Healthcare Plans: What Plan is Best for You?

There are a variety of healthcare Marketplace plans that each have their own specifications. Some plans will restrict your provider options for your network, while others may have you pay a higher cost if you use providers outside of your network.

What is a managed healthcare plan?

The idea of managed healthcare insurance plans became popular later in the 20th century. These plans offer policies to individuals within a group or employer. The managed healthcare plan helps the beneficiaries with better rates by using services within their plans network.

Marketplace plans

The options you have may depend on the location you live. The plan options are often referred to as Bronze, Silver, Gold, and Platinum, not to be confused with the olympic medals. Generally, each plans healthcare costs are:

  • Bronze covers 60%, you pay 40%.
  • Silver covers 70% , you pay 30%.
  • Gold covers 80%, you pay 20%.
  • Platinum covers 90%, you pay 10%.

Health Maintenance Organization (HMO)

The HMO plans offer a lower monthly premium and lower cost-sharing expenses, or your share of the expenses you pay out of pocket,  for those who have less restrictions in their network. However, they require primary care provider referrals and will not pay for services outside of the plans network.

Preferred Provider Organization (PPO)

The PPO plan name speaks for itself. The Preferred Provider Organization has a network with providers that they prefer you to use, but will still pay for services out-of-network. However, the costs are lower if you stay in your preferred network rather than going out-of-network for services. Since they are less restrictive with their plan, the monthly premiums are often higher.

While PPO plans have gone down in popularity for individuals, they are still common for employer-sponsored healthcare plans.

Point-of-service plan (POS)

POS plans are similar to the HMO plans, but they are less restrictive when it comes to your in-network and out-of-network coverage. POS is a mixture of an HMO and a PPO healthcare plan. Under specific circumstances, your POS plan will allow you coverage like a PPO plan. 

You have more options available to you under a POS plan than with an HMO plan, but you may still need a referral for a specialist from your primary care provider. While you can have services done that are out-of-network, you will have to pay more unless you use in-network services.

Exclusive Provider Organization (EPO)

EPO plans are named due to how exclusive they are with their services and networks. If you have an EPO plan, you are required to stay with your providers that are listed in-network, otherwise EPO will not pay. While they are strict on who you can see while having your expenses covered, an EPO will not require a referral from your primary physician.

It is important to understand the difference between each of these common plans to know which plan is best for you. On top of your budget, knowing your in-network options could be crucial in how you decide on the right plan for you.


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Medicare World Blog