Health insurance plan & network types: 

HMOs, PPOs, and more

There are different types of Marketplace health insurance plans designed to meet different needs. Some types of plans restrict your provider choices or encourage you to get care from the plan’s network of doctors, hospitals, pharmacies, and other medical service providers. Others pay a greater share of costs for providers outside the plan’s network.

Types of Marketplace plans

Depending on how many plans are offered in your area, you may find plans of all or any of these types at each metal level – Bronze, Silver, Gold, and Platinum.

Some examples of plan types you’ll find in the Marketplace:

• Exclusive Provider Organization (EPO): A managed care plan where services are covered only if you use doctors, specialists, or hospitals in the plan’s network (except in an emergency).
• Health Maintenance Organization (HMO): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.
• Point of Service (POS): A type of plan where you pay less if you use doctors, hospitals, and other health care providers that belong to the plan’s network. POS plans require you to get a referral from your primary care doctor in order to see a specialist.
• Preferred Provider Organization (PPO): A type of health plan where you pay less if you use providers in the plan’s network. You can use doctors, hospitals, and providers outside of the network without a referral for an additional cost.

There are a few ways to check if your doctor is in-network with your health insurance plan: 

Call your insurance company

You can call the member services number on the back of your health insurance card to ask if your doctor is in-network. You can also call your insurance company to ask about the cost of services and what you'll need to pay. 

Check your insurance company's website

Many insurance companies have a "find your doctor" option on their website. 

Call your doctor's office

You can call your doctor's office to ask if they are in-network with your insurance plan. You should have your specific health plan and doctor's name when you call. 

It's important to note that a doctor may accept insurance but still be out-of-network for your specific plan. Insurance companies regularly review and amend their networks

• You're probably paying full price. When health insurers don't have a contracted relationship with out-of-network doctors and facilities, they can't control what is charged for services. And rates may be higher than the discounted in-network rate.
• You may have to pay the difference. If your doctor's bill is higher than what your plan will pay, you might have to pay the difference. Many health plans list an amount that is the most they'll pay for a certain service received out-of-network. If the doctor or facility charges more than your plan is willing to pay, you could be responsible for paying the difference in addition to your deductible, copay, and/or coinsurance. In-network doctors and facilities have agreed not to charge you more than the agreed-upon cost.
• Your share of costs is different—and usually higher. A copay is the amount you pay for covered health services at the time you receive care. There are no copays when you use a doctor or facility that is out-of-network. But you are responsible for paying the coinsurance, or a percentage of covered charges. This may be much higher than the in-network copay or coinsurance amount.

Prescription drug coverage can vary by plan, but some things to consider include: 

Formulary

A list of drugs that are covered by the plan, which includes both generic and brand-name drugs. Formulary lists must include at least two drugs from each of the most commonly prescribed drug classes. 

Coverage gap

Once you reach the coverage gap, you'll pay a discounted rate for covered drugs, usually 25% of the cost. 

Drug management programs

Some plans may limit coverage of certain drugs, such as opioids and benzodiazepines, if they believe your use of these drugs is unsafe. 

Cost-sharing

You and your plan usually split the cost of covered drugs, with you paying your share and your plan paying its share. 

Vaccines

Some plans, like Medicare Part D, may cover certain vaccines, such as the Shingles vaccine, Tdap, and vaccines for the flu and pneumonia. 

"Out-of-pocket costs" refer to the portion of medical expenses that a patient is personally responsible for paying, including copays (fixed fees for specific services), deductibles (the initial amount you pay before insurance kicks in), and coinsurance (a percentage of the cost you share with your insurance company) for covered healthcare services; essentially, any medical cost not fully covered by your health insurance plan. 

Key points about out-of-pocket costs: 

Components:

The main components of out-of-pocket costs are copays, deductibles, and coinsurance. 

Out-of-pocket maximum:

Most health insurance plans have an "out-of-pocket maximum" which is the highest amount you will have to pay in a year before your insurance covers 100% of eligible costs. 

Importance of understanding:

It's crucial to understand your out-of-pocket costs when choosing a health insurance plan, as it can significantly impact your overall healthcare expenses.