If you want your new health insurance to start on January 1st then you must enroll before December 15th. You can still enroll until January 15th, but your policy won’t start until February. We know you’ve been hearing OEP over and over the last few months, but that’s because we can’t stress enough how important it is. Not only is this the only time you can enroll in a new plan. This is the only time you can review your current plan and make sure you have all of the coverage you need within your budget. You’re in control of your health and there’s plenty of plan and carrier options out there ready to help you stay in control.
Guaranteed Coverages
The Affordable Care Act (ACA) brought a lot of change to the health insurance industry. All of which center around making sure everyone has access to affordable coverage. The ACA introduced the “10 essential benefits”. Which are 10 health care benefits that every marketplace plan must cover regardless of tier, plan type, cost, or provider.
Ambulatory patient services
Emergency services
Hospitalization
Laboratory services
Mental health and substance use services
Pregnancy, maternity, and newborn care
Prescription medications
Preventative and wellness services and chronic disease management
Pediatric services
Rehabilitative and habilitative services
Not only are health plans required to cover these benefits. Insurers are also prohibited from denying or charging more for a plan based on pre-existing conditions. So thanks to the ACA you are guaranteed to get a plan that covers all of your basic needs without having to pay an arm and a leg.
Your Options
You’ve got nothing but options during the OEP, from plans to plan tiers to possible subsidies and then some. Let’s go over the basics and give you a good starting point in your search.
The first thing you have to do is choose a plan type. While every Marketplace plan is legally required to cover the “10 essential benefits”. Plans can offer extra benefits and they can all be structured differently. So, this step is a big one because it sets the foundation for the coverage you have.
HMOs offer you the option of choosing from a local network of participating physicians, hospitals, and other healthcare providers and facilities. As part of these health insurance policies, you must choose a primary care physician (PCP) from this network. Your primary care physician (PCP) will get to know you and help you organize all of your medical care. They are also responsible for referring you to any specialists. Without this recommendation, your HMO would not cover a specialist visit. A HMO plan’s out-of-pocket costs are frequently lower than those of other types of health plans as long as you stay in-network. In general, an HMO may make sense if you prioritize lower expenses and don’t mind using a PCP to oversee your treatment.
PPOs offer a vast network of participating providers, so you can choose from a wide range of hospitals, clinics, and healthcare facilities. Unlike HMOs, PPOs provide some coverage for providers outside of their network, but not as much as they would for an in-network provider. Another significant distinction between PPOs and HMOs is that you aren’t required to choose a PCP and you can see a specialist without a referral. A PPO is often a smart option if you want more control over your options and are willing to pay extra for it. It would be especially useful if you travel frequently because you would not have to see a primary care physician.
Exclusive Provider Organization (EPO)
EPOs also allow you to choose from a network of participating providers. Except in cases of emergency, most EPO plans do not cover care outside of their network. As a result, if you see a provider or facility that is not part of the plan’s local network, you will most likely be paying for the whole cost of services. As for PCPs, EPOs can go either way, some require you to choose a PCP and others don’t, it just depends on the insurance company you choose. In either case, as long as the specialist is in the plan’s network, you will not require a referral from your primary care physician. If you need cheaper monthly rates and are ready to pay a larger deductible when you need medical treatment, an EPO plan may be for you.
Point of Service (POS)
POS plans combine the benefits of PPOs and HMOs. A POS’s provider network, like an HMO, is often smaller than a PPO plan, and in-network care expenses are typically lower, as with a PPO. In POS plans, you must select a primary care provider (PCP) from a network of physicians and other primary care specialists. If you need to see a specialist, you have to get a referral from your PCP.
However, just like with PPO, you have the option of seeing in-network or out-of-network experts. However, if you visit an out-of-network provider, your part of the costs will be higher, and you will be responsible for submitting any claims. POS insurance plans are a terrific option for many people, especially if you’re looking to save money and don’t need out-of-network healthcare services. If you are prepared to coordinate your care through a primary care physician, a POS plan may be perfect for you.
Health Expense Accounts
There are also separate savings plans you can buy to help you save up money specifically for medical costs.
An HRA, or health reimbursement arrangement, is a form of health expense account provided and owned by your employer. Because they own the HRA, your employer is the only one who can contribute to it. They can also determine if you can roll over unused cash to the next year. The money in it is used to pay for eligible expenses including medical, pharmaceutical, dental, and vision care, as defined by the employer.
A health savings account (HSA) is a bank account that you can use to pay for qualifying health care bills or to save for retirement. An HSA is available when combined with a qualified high-deductible health plan (HDHP), which has lower premiums/plan contributions and greater deductibles than a regular health plan. If you have an employer-sponsored health plan, the account is opened through the HSA provider chosen by your company. You, your employer, and others can contribute to your HSA up to a yearly limit determined by the IRS.
Flexible Spending Account (FSA)
An FSA is an employer-sponsored savings account that helps manage out-of-pocket healthcare bills. FSAs are tax-advantaged accounts, which means you can contribute to them before taxes and spend the money tax-free. FSAs allow account holders to save for eligible healthcare expenses by deducting pre-tax money directly from their paychecks. FSA funds can be used to cover deductibles, co-pays, and medical visits for you, your spouse, and any qualified dependents. Employers may contribute to their employees’ FSAs, but they are not obligated to do so.
Health Insurance Subsidies
Marketplace plans have two types of subsidy. The first type, known as the premium tax credit, lowers your monthly insurance costs. The cost sharing reduction (CSR) is a sort of financial aid that reduces your deductibles and other out-of-pocket payments when you visit the doctor or stay in the hospital. To get either sort of financial aid, you must enroll in a health insurance Marketplace plan.
Premium Tax Credit
A premium tax credit, sometimes known as a premium subsidy, is a tax credit that reduces or eliminates the amount of money that you would otherwise have to pay for getting individual or family health insurance. Unlike other tax credits, the premium tax credit can (and typically is) given upfront and all year. Each month, the IRS gives money to your health insurer, so you don’t have to pay as much yourself. Your tax return is then compared with the premium tax credit the following spring. You can also choose to pay full price for a health plan in your state’s exchange and then get the full premium tax credit on your tax return. Few people do this, however, because the cost of coverage without the advance premium tax credit is often out of reach for those who do qualify for the premium tax credit.
You must apply for coverage through the Marketplace and give information about your age, residence, household size, citizenship status, and expected income for the following year in order to receive the premium tax credit. Following the submission of the application, you will receive a decision indicating the amount of premium tax credit you qualify for. You can then choose to have the tax credit paid in advance, claim it later when filing your tax return, or a combination of the two.
Who’s Eligible?
To be eligible for the premium tax credit beginning in 2024, you must meet the following requirements:
Have a household income of at least the Federal Poverty Level (FPL), which is $14,580 in 2024.
Lack of affordable coverage through a workplace (including a family member’s employer)
Not be eligible for Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).
Have U.S. citizenship or proof of legal residency (Lawfully present immigrants with household incomes less than 100 percent FPL may also be eligible for tax subsidies through the Marketplace if all other eligibility standards are met).
If you’re married you must file your taxes jointly.
Cost Sharing Reduction
Cost sharing reductions are the second type of financial aid available. When you utilize covered health care services, cost sharing reductions reduce your out-of-pocket costs related to deductibles, copayments, and coinsurance. Cost sharing reductions are available to anyone who qualifies for a premium tax credit and has household incomes ranging from 100 to 250 percent of the poverty line. Cost sharing reductions (CSR) are only available through silver plans, as opposed to the premium tax credit, which can be applied to any metal level of coverage. CSRs are applied to a silver plan for qualified individuals, basically making deductibles and other cost sharing more comparable to that of a gold or platinum plan. Individuals earning between 100 and 250 percent of the FPL can use their premium tax credit to any metal level plan, but they can only receive cost sharing subsidies if they choose a silver-level plan.
Health Plan Tiers
When you buy health insurance through the federal or state Marketplace, the plans available are divided into four metal tiers: bronze, silver, gold, and platinum. The metal tiers allude to the portion of your medical treatment that each tier will cover, not the quality of care you will receive with one of these plans. Which plan tier you pick determines the amount of the bill you pay. The higher the coverage, the higher the cost, but the less you will have to pay out of pocket.
Bronze plans will cover 60% of costs; you will pay 40%
Silver plans will cover 70% of costs; you will pay 30%
Gold plans will cover 80% of costs; you will pay 20%
Platinum plans will cover 90% of costs; you will pay 10%
Why You Need Health Insurance
The most important advantage of having health insurance is having access to the care you need. Health insurance provides you with access to a vast network of doctors, specialists, hospitals, and laboratories. This network collaborates with you and with one another to assist you in focusing on prevention and wellness. In fact, the majority of healthcare plans provide free preventative services, such as immunizations and testing. To help you stay healthy and avoid illnesses and their consequences.
Furthermore, the Affordable Care Act requires Marketplace plans to cover pre-existing diseases. This means that even if you have a pre-existing condition, you can receive care without being rejected coverage or charged extra because of it. Because you’ll have regular access to the doctors and experts you need, your healthcare plan will also help you manage your care for any chronic illnesses you’re living with.
Your health insurance covers all of the greatest strategies to maintain your health. Having access to this type of continuous care can essentially lead to a longer and better quality of life. According to the National Library of Medicine, persons between the ages of 17 and 64 who did not have health insurance had a 40% higher mortality risk than those who did!
How EZ Can Help
Working with an agent saves you time and stress because you won’t have to decipher legal language or read fine text. Agents handle all of the legwork. So, you may rest assured that your coverage will best match your financial and medical requirements. Not to mention, EZ agents can save you hundreds of dollars on your health insurance premiums each year. We accomplish this by scouring the market for the most affordable plans, both on and off the market. In addition to locating and utilizing any available savings.
We don’t only assist you in finding a plan, we also assist you in keeping it up to date. When the time comes, we are also here to help you in filing claims with your insurance company and renewing your policy. To begin, enter your zip code in the box below. Alternatively, contact 877-670-3557 to speak with one of our licensed agents.
When you’re shopping for health insurance, you’ll come across several plan types to choose from. Two of which are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). While there are several other options, these two are the most common. Both plans provide various types of coverage, including network sizes, costs, and coverages outside of the network. You will want to make sure the plan you choose will fit all of your needs and allows you to stay within budget. Choosing one isn’t as difficult as it may seem. Below we’ve detailed both of these options and compared them for you.
An HMO is an affordable health insurance plan that provides a network of healthcare providers to choose from. HMOs offer cheaper coverage because their networks are smaller than other plan’s networks. HMOs are known for their lower lates, but that comes with less flexibility. The network is the key to this type of coverage. Providers within this network such as doctors, hospitals, labs, and specialists all have contracts with the insurance company. Meaning they are paid to offer you, the policyholder, a variety of health services for less. Typically you’ll find that these networks operate in a specific geographic area. Meaning you must see providers within that area. It also means that any fees associated with the plan will be based on the population of your area. For example, heavily populated areas with higher cost of living will result in higher fees. Even though HMOs offer less flexibility, their premiums are lower than other plans. Their smaller networks and the fact that you are being directed to the plan’s providers rather than out-of-network providers, means the savings pass directly to you.
With PPO plans, you have much more freedom in choosing your doctors and hospitals. Staying in-network always provides the best benefits because you pay less for those services. However, unlike HMOs, you are not restricted to in-network providers, but it will cost you more than seeing in-network providers. PPO plans are generally more expensive due to their higher monthly premiums. Nonetheless, the increased flexibility more than compensates for the higher costs. You are not required to choose a primary care provider (PCP) and you can visit any doctor, including specialists, without a referral. All of this means you pay more and you are responsible for managing and coordinating your own care without a PCP, unless you decide to choose one.
How They Differ
Now that you know the basics of each plan, let’s compare the differences between HMOs and PPOs including network size, the ability to see specialists without referrals, costs, and out-of-network coverage. Compared to PPOs, HMOs are much more affordable. However, PPOs offer a lot more flexibility with their specialists and larger networks. As well as their out-of-network coverage. Below we’ll go into these comparisons a little more.
Networks
Both HMO and PPO plans have provider networks. In exchange for access to a health plan’s members, network providers agree to offer discounts to reduce health care costs. This saves money for health insurers, but it also saves money for you, the policyholder; savings for the insurer can translate into lower premiums, deductibles, and copayments. Overall, PPO networks include more physicians and hospitals than HMO networks, giving you more options. However, networks will vary from insurer to insurer and plan to plan; therefore, it is best to look into each plan’s network before making a decision.
Primary Care Physicians
The majority of HMOs will require you to choose a primary care physician, who will serve as your primary point of contact for medical care. If your primary care physician determines that specialized care is medically necessary, he or she will refer you to a specialist for treatment. Specialists costs will not be covered without a referral from a primary care physician. PPOs, on the other hand, typically do not require the selection of a PCP, and you can typically see a specialist without a referral and those costs are covered.
Out-Of-Network Coverage
For both PPO and HMO plans, you will get the lowest costs for care if you use in-network providers. The coverage for out-of-network care varies significantly between these two types of plans. Out-of-network services are typically not covered at all by HMOs, except in the case of an emergency. PPO plans typically provide some coverage for these services, but as always, staying in the network will always mean less money out of your pocket.
Costs
PPO plans will typically be more expensive than HMO plans due to the additional coverage and flexibility they provide. When we consider health plan costs, we typically consider monthly premiums. HMO premiums are typically less expensive than PPO premiums. The plan’s deductible is also another factor you need to consider. This is the amount of out-of-pocket health care expenses you must pay before your plan begins to pay for your expenses. When HMOs have deductibles, they tend to be less expensive than PPO deductibles. Below we’ve provided examples of costs for each plan.
HMO Costs
These are examples based on average costs, they can vary depending on your age, where you live, plan tier, as well as number of dependents.
21-year-old – Single $342, couple $684, couple with 1 child $944
30-year-old – Single $390, couple $780, couple with 1 child $1,040
40-year-old – Single $438, couple $877, couple with 1 child $1,1,37
50-year-old – Single $613, couple $1,226, couple with 1 child $1,487
Along with lower premiums, HMOs typically have lower or sometimes no deductibles. A copayment is instead required for each clinical visit, test, and prescription. Copayments for HMOs are typically $5, $10, or $20 per service, which reduces out-of-pocket expenses and makes HMO plans more affordable.
PPO Costs
As with all plans, the premiums are determined by age, location, and the number of dependents covered by the plan. For instance, average monthly premiums for PPOs are:
21-year-old – Single $404, couple $807, couple with 1 child $1,113
30-year-old – Single $458, couple $916, couple with 1 child $1,222
40-year-old – Single $516, couple $1,032, couple with 1 child $1,528
50-year-old – Single $721, couple $1,442, couple with 1 child $1,748
PPO plans typically have higher deductibles than HMOs. Generally the annual deductible for a PPO is around $1,500. If your PPO plan includes a copayment for office visits, you will only pay a small copayment when you see a doctor in your preferred network. If your PPO plan does not include a copayment benefit, your visit will be charged at the preferred network rate and applied to your deductible. Going “out-of-network” will be more expensive. You may also have to pay the doctor directly and then submit a reimbursement claim to your PPO.
PPOs also have 2 out-of-pocket maximums. Meaning you will never pay more than a preset amount for your care in a given year. One limit applies only to in-network costs, while the other applies to both in-network and out-of-network costs. If you require extensive care or expensive procedures, these limits may protect you from racking up excessive costs. In 2023, the out-of-pocket maximum for Marketplace plans cannot exceed $9,100 for individuals and $18,200 for a family. This means that in 2023, if you pay more than $9,100 in out-of-pocket medical expenses, your insurance will cover 100% of any additional medical expenses.
Choosing Between Them
When deciding between these two plans, it’s best to consider how much you are willing to pay, how much coverage you need, and whether or not you want to see a PCP less frequently or see a specialist without a referral. In general, HMOs have a lower cost. So, if your budget is your biggest deciding factor then an HMO may be for you. With lower premiums and low to no deductibles being your benefits, but you’ll sacrifice the flexibility of choosing providers. If you travel a lot or have a chronic condition, you may need to see a doctor once or twice outside of your network. So, if you’re more interested in flexibility, a PPO plan may be the better option.
Now that you know the difference between the two main types of health insurance, you might have a better idea of which plan fits you better. If you need more information you can start by visiting our PPO and HMO pages. These pages have more in depth explanations of each plan’s benefits and limitations. Everyone should carefully consider their health insurance options. Your particular circumstances, such as your health, finances, and quality of life, will determine the optimal plan for you. EZ.Insure can assist you in choosing between the two plans and determining which one best meets your needs and budget. We provide you with a local licensed agent who will go over all available plans in your area. They will provide you with quotes for all available plans, explain what each plan covers, and sign you up at no cost. Our services are entirely free! Simply enter your zip code in the box below to receive your free instant quotes, or contact an agent by calling 877-670-3557.
