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Types of Health Insurance Plans

The three most common types of health insurance plans are Health Maintenance Organizations (HMOs), Participating Provider Options (PPOs) and Consumer Directed Health Plans (CDHPs).

HMOs

An HMO is a type of health insurance plan that gives you access to certain doctors and hospitals, often called network or contracting doctors and hospitals (sometimes called "providers").

HMO basics:

  • When you sign up, you select a primary care physician (PCP) from a network of doctors.
  • Your PCP is your first point of contact for most of your basic health care needs.
  • Women can also select an OB/GYN for obstetrical and gynecological care.
  • If you need special tests or need to see a specialist, your PCP will give you a referral to see another doctor.

HMO Members Rights and Responsibilities

The bottom line:

  • HMO plans generally have lower up-front costs, or premiums, than other types of plans.
  • They usually feature low deductibles or no deductible at all. A deductible is the amount you pay out-of-pocket before your plan kicks in.
  • HMOs usually feature low copayments as well. Copayments are set amounts (usually a dollar amount or a percentage) that you pay for care. An example of a copayment is $20 for each office visit.
  • HMO plans generally provide the highest level of coverage - meaning the lowest cost for you - when you use doctors, hospitals and specialists that are in the network.
  • If you seek care outside the network, your care may not be covered at all.

PPOs

Like HMOs, PPOs often feature a network of doctors, specialists and hospitals; however, there are some key differences between the two types of plans.

PPO basics:

  • With a PPO plan, you don't have to choose a primary care physician.
  • You have the option of receiving care from doctors, hospitals and specialists in the network or outside the network, and you don't always need a referral to see a specialist.

Key features:

  • PPO plan premiums are generally higher than HMO plans, which means you'll have to pay more up front.
  • When you receive care from a doctor or hospital that is in the network, your costs tend to be lower.
  • When you receive care from a doctor or hospital outside the network your costs are likely to be higher, and, in some cases, your care may not be covered at all.
  • PPO plans usually have a deductible. So, for example, if your PPO plan has a $500 deductible, your coverage doesn't begin until you've paid out-of-pocket for the first $500 of your own medical expenses. Preventive care services are not subject to the deductible.

CDHPs and the HSA Option

Consumer Directed Health Plans (CDHPs) often involve pairing a high deductible PPO plan with a tax-advantaged account, such as a Health Savings Account (HSA). For an individual to establish an HSA and contribute money to the account each year, he or she must be considered an HSA-eligible individual. Eligibility includes enrollment in an HSA-qualified high deductible health plan.

Key features:

  • If the plan uses a PPO network, you don't have to choose a primary care physician.
  • You have the option of receiving care from doctors, hospitals and specialists in the network or outside the network, and you don't always need a referral to see a specialist.

The bottom line:

  • When a CDHP includes a high deductible health plan, premiums are often lower than other types of health plans because you are responsible for a greater share of your health care costs.
  • If the health plan is an HSA-qualified high deductible health plan, and you are an HSA-eligible individual, you may establish an HSA and make contributions to the account each year.
  • An HSA is a savings account that you can use to cover a wide range of qualified medical expenses. HSAs have special tax advantages and are regulated by the Treasury Department.1

Resources

For more information about individual health insurance plans, visit the U.S. Agency for Healthcare Research and Quality (AHRQ) . This website provides guidance on choosing a health insurance plan.



1 Health Savings Accounts (HSA) have tax and legal ramifications. Blue Cross and Blue Shield of Illinois does not provide legal or tax advice, and nothing herein should be construed as legal or tax advice. These materials, and any tax-related statements in them, are not intended or written to be used, and cannot be used or relied on, for the purpose of avoiding tax penalties. Tax-related statements, if any, may have been written in connection with the promotion or marketing of the transaction(s) or matter(s) addressed by these materials. You should seek advice based on your particular circumstances from an independent tax advisor regarding the tax consequences of specific health insurance plans or products.