The health insurance landscape can be tricky to navigate. Here’s a start-to-finish guide to choosing the best plan for you and your family, whether it’s through the federal marketplace or an employer.
Step 1: Find your marketplace
Most people get health insurance through an employer. If you’re one of them, you won’t need to use the government insurance exchanges, or marketplaces. Essentially, your work is your marketplace.
If your employer offers health insurance and you still wish to search for an alternative plan in the exchanges, you can. But plans in the marketplace are likely to cost a lot more. Most employers that provide insurance pay a portion of workers’ premiums, so they’ll likely offer the least expensive option.
If your job doesn’t provide a health insurance benefit, shop on your state’s Affordable Care Act marketplace, if available, or the federal marketplace to find the lowest premiums. Start by going to HealthCare.gov and entering your ZIP code. You’ll be sent to your state’s exchange if your state is green on the map below. Otherwise, you’ll use the federal marketplace.
You can also purchase health insurance through a private exchange or directly from an insurer. If you choose these options, you won’t be eligible for premium subsidies, which are income-based discounts on your monthly premiums.
Step 2: Compare types of health insurance plans
You’ll encounter some alphabet soup while shopping for plans; the most common types are HMOs, PPOs, EPOs, or POS plans. The kind you choose will help determine your out-of-pocket costs and which doctors you can see.
While comparing plans, look for a summary of benefits. Online marketplaces usually provide a link to the summary and show the cost near the plan’s title. A provider directory, which lists the doctors and clinics that participate in the plan’s network, should also be available. If you’re going through an employer, ask your workplace benefits administrator for the summary of benefits.
COMPARING HEALTH INSURANCE PLANS: HMO VS. PPO VS. EPO VS. POS
|Plan Type||Do you have to stay in network to get coverage?||Do procedures & specialists require a referral?||Best for you if:|
|HMO: Health Maintenance Organization||Yes, except for emergencies.||Yes||You want lower out-of-pocket costs and a primary doctor that coordinates your care for you, including ordering tests and working with your specialists.|
|PPO: Preferred Provider Organization||No, but in-network care is less expensive.||No||You want more provider options and no required referrals.|
|EPO: Exclusive Provider Organization||You want lower out-of-pocket costs but no required referrals.|
|POS: Point of Service Plan||No, but in-network care is less expensive; you need a referral to go out of network.||You want more provider options and a primary doctor that coordinates your care for you, including ordering tests and working with your specialists.|
When comparing different plans, put your family’s medical needs under the microscope. Look at the amount and type of treatment you’ve received in the past. Though it’s impossible to predict every medical expense, being aware of trends can help you make an informed decision.
If you choose a plan that requires referrals, such as an HMO or POS, you must see a primary care physician before scheduling a procedure or visiting with a specialist. Because of this requirement, many people prefer other plans.
POS and HMO plans may be better if you don’t mind your primary doctor choosing specialists for you; one benefit of this system is that there’s less work on your end, since your doctor’s staff coordinates visits and handles medical records. If you do choose a POS plan and go out of network, make sure to get the referral from your doctor ahead of time to reduce out-of-pocket costs.
If you’d rather choose your doctors, you might be happier with a PPO or EPO. An EPO may also help you lower costs as long as you find providers in network; this is more likely to be the case in a larger metro area. A PPO might be better if you live in a remote or rural area with limited access to doctors and care, as you may be forced to go out of network.
Step 3: Compare health plan networks
Costs are lower when you go to an in-network doctor because insurance companies contract lower rates with in-network providers. When you go out of network, those doctors don’t have contracted rates, which costs your insurance company, and you, more.
If you have preferred doctors and want to keep seeing them, make sure they’re in the provider directories for the plan you’re considering. You can also directly ask your doctors if they take a particular health plan.
If you don’t have a preferred doctor, you’ll probably want a plan with a large network so you have more choices. A larger network is especially important if you live in a rural community, since you’ll be more likely to find a local doctor who takes your plan.
Eliminate any plans that don’t have local in-network doctors and those with very few provider options compared with other plans.
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