You can obtain health insurance through your employer, the marketplace, or directly from providers. The type of health insurance you choose depends on factors such as access to employer-sponsored plans, age, location, family structure, and healthcare needs.
Securing health insurance in the U.S. can be a complicated process, but it can also be as simple as having a job that offers health benefits. Almost everyone in the country has health insurance coverage[0], so it’s crucial to understand how it operates.
Types of health insurance plans
There are various types of health insurance plans, each with its own pros and cons.
Comparing health insurance plans: HMO vs. PPO vs. EPO vs. POS
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Do you have to stay in-network to get coverage?
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Do procedures & specialists require a referral?
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HMO: health maintenance organization
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Yes, except for emergencies.
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Lower out-of-pocket costs and a primary doctor who coordinates your care for you, but less freedom to choose providers.
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PPO: preferred provider organization
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No, but in-network care is less expensive.
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More provider options and no required referrals, but higher out-of-pocket costs.
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EPO: exclusive provider organization
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Yes, except for emergencies.
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Lower out-of-pocket costs and usually no required referrals, but less freedom to choose providers.
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POS: point of service plan
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No, but in-network care is less expensive.
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More provider options and a primary doctor who coordinates your care for you, with referrals required.
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HMO: health maintenance organization
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Lower out-of-pocket costs and a primary doctor who coordinates your care for you, with referrals required to see a specialist. You must stay in-network except for emergencies.
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PPO: preferred provider organization
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More provider options and no required referrals, but higher out-of-pocket costs. You can go out of network, but care will be more expensive.
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EPO: exclusive provider organization
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Lower out-of-pocket costs and usually no required referrals, but less freedom to choose providers. You must stay in-network except for emergencies.
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POS: point of service plan
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More provider options and a primary doctor who coordinates your care for you, with referrals required to see a specialist. You can go out-of-network, but care will be more expensive.
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High-deductible health plans
High-deductible health plans (HDHPs) have a higher deductible than standard health plans and are available in various plan types, including HMOs and PPOs. HDHPs have lower premiums but higher upfront costs, as you must cover the deductible before insurance kicks in[0]. HDHPs can also provide access to a health savings account (HSA) for saving pretax funds for healthcare expenses (you must enroll in an “HSA-eligible” HDHP).
Where to buy health insurance
Understanding Health Insurance Plans
Health insurance plans available on the marketplace are categorized into metal “tiers” – Bronze, Silver, Gold, and Platinum. These tiers indicate the percentage of costs you will be responsible for covering. Additionally, there are Catastrophic plans with high deductibles and low premiums, but they are only accessible to individuals under 30 or those who qualify for a hardship exemption.
Bronze plans cover 60% of your healthcare costs, while Platinum plans cover 90%. If you are eligible for extra savings, enrolling in a Silver plan is required to access those savings.
Off-Marketplace Health Insurance
You have the option to purchase health insurance directly from an insurance company or broker, but you will not qualify for premium tax credits or subsidies to assist with the costs.
Enrollment Periods for Health Insurance
Unlike some other forms of insurance, you cannot sign up for health insurance at any time. Enrollment periods include:
- You started a new job that offers health benefits.
- Annual open enrollment from Nov. 1 to Jan. 15.
- You experience a qualifying life event, such as marriage or having a baby, which may trigger a special enrollment period.
Changes to your coverage can be made during your employer’s open enrollment period or general open enrollment in your state if you have a marketplace or off-marketplace plan. Special enrollment periods are also available for specific life events.
Comparing Health Insurance Plans
The process of comparing health insurance plans varies depending on how you obtain coverage. Considerations when choosing a plan include evaluating your budget, network flexibility, preferred doctors, scope of services, and prescription coverage.
What to Do If You Lose Coverage
If you lose employer-based health insurance, options include enrolling in COBRA coverage, signing up for a marketplace plan due to a qualifying life event, or purchasing off-marketplace health coverage. Each option has its own set of benefits and considerations.
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