Types of health insurance policies in the U.S.: a detailed guide

Health insurance in the United States is diverse and may include different types of plans, such as HMO, PPO, EPO, POS, HDHP and HSA. Each of these plans has its own features and benefits designed for the different needs and requirements of the insured. Let's take a look at their detailed features.

HMO (Health Maintenance Organization) Insurance Policy

An HMO is a healthcare system that unites the insurer, providers and patients into a single network. The main idea is to limit the patient outside the network to ensure coordinated and affordable health care. A referral from a physician may be necessary to use out-of-network services.

An HMO combines an insurer, doctors, hospitals and other health care providers into a single network. Patients choose a primary care physician (PCP) from the network to coordinate their care.

For specialty care, patients usually need a referral from their PCP. This ensures coordinated and efficient care.

HMOs typically have a low premium cost compared to other types of insurance plans. However, patients may incur additional costs when visiting out-of-network physicians.

Patients are required to receive medical services in the HMO network. The supply of out-of-network doctors and hospitals may be limited or non-existent.

Most often, the HMO will set a co-payment (flat fee for service) or co-payments for physician visits. There is a high likelihood that most medical services will be fully or partially covered by insurance.

HMOs emphasize preventive health care and a healthy lifestyle. Regular medical check-ups and preventive measures are usually covered by the insurance plan.

Advantages of HMOs

1. The premium cost is usually low;

2. High level of coordinated medical care.

Disadvantages of HMOs:

1. Limited choice of doctors and hospitals;

2. Referral required for out-of-network visits.

PPO (Preferred Provider Organization) Insurance Policy

A PPO is a type of insurance plan that offers a greater choice of doctors and hospitals if they belong to the "preferred" network. Patients may also receive medical services outside the network, but on less favorable terms.

The PPO also has its own network of doctors and hospitals, but it is less limited than the HMO. Patients can receive medical services outside the network, but at reduced prices within the network.

A distinguishing feature of the PPO is that patients are not required to receive referrals for specialist consultations. They can contact specialists directly without wasting time getting referrals.

PPOs typically have lower copayments and deductibles for in-network medical services. Patients usually pay less for in-network medical services. If a patient chooses to receive out-of-network health services, the cost will be higher, but still may be an acceptable discount.

The difference between PPOs is that patients can receive medical services without having to choose a primary care physician. There is no need for referrals for specialty consultations. The PPO offers more flexibility in choosing medical providers and does not require referrals for many services.

Advantages of the PPO:

Greater choice of physicians and hospitals;

2. No referrals required for out-of-network visits.

Disadvantages of PPO:

Higher premium cost compared to HMO. 2;

2. Cost of out-of-network services may be higher.

EPO (Exclusive Provider Organization) Insurance Policy

The EPO is a combination of HMO and PPO elements. Doctors and hospitals must belong to the network, but patients may receive some out-of-network services without a referral.

An EPO also has a network of doctors and hospitals, but may be more limited compared to a PPO, similar to an HMO. Patients may receive out-of-network medical services, but they are usually not covered by the insurance plan.

The peculiarity of the EPO is that many medical services do not require a referral from a primary care physician. Patients can see specialists on their own without prior approval.

The EPO network typically has lower copayments and deductibles for medical services compared to out-of-network services. Patients pay less for in-network visits and procedures.

The EPO does not provide out-of-network coverage (except in medical emergencies or other exceptional circumstances). If a patient chooses to receive medical services out-of-network, he or she is usually not covered. Compared to an HMO, an EPO may not require you to choose a primary care physician or referrals for specialist consultations. An EPO offers the flexibility to choose in-network medical providers without referrals.

Advantages of the EPO:

1. premium cost is generally lower than the PPO;

2. Ability to choose in-network physicians and hospitals.

Disadvantages of EPO:

1. cannot get all out-of-network services without a referral;

2. Limited choice compared to PPO.

POS (Point of Service) Policy

POS is a flexible plan that combines HMO and PPO features. Patients can choose in-network doctors and hospitals or receive out-of-network services for an additional cost.

A POS has its own network of doctors and hospitals. If a patient receives medical services within the network, they are usually covered by the insurance plan.

For specialty medical services, a referral from a primary care physician may be necessary. Patients should choose a primary care physician to coordinate their care. If the patient chooses to receive out-of-network medical services, the cost may be higher, but is partially covered by the insurance plan.

Typically, the POS allows patients to see specialists without a referral. Flexibility to choose out-of-network providers. If the patient receives medical services outside the network, he or she may have to pay additional costs, such as co-payments and deductibles. In the case of urgent medical care, POS can cover services even outside the network, providing patients with more flexibility.

Advantages of POS:

1. greater choice of doctors and hospitals;

2. Ability to receive services outside the network.

Disadvantages of POS:

1. Generally higher premium cost compared to HMOs;

2. Requires a referral for specialty services.

HDHP (High Deductible Health Plan)

An HDHP is a plan with a high level of out-of-pocket costs, where the patient has a large additional cost before insurance begins to cover the expenses. This type of plan is often used in conjunction with a health savings account (HSA).

HDHPs have a high deductible, which is the amount the patient must pay before insurance begins to cover expenses. HDHP patients pay most of their medical expenses until they reach the deductible. HDHPs can encourage patients to be prudent with their health and effectively manage their medical expenses.

Many HDHPs are linked to a Health Savings Account (HSA), which allows patients to save money for medical expenses with tax benefits. HDHP patients can often choose the doctors of their choice, as they are not necessarily affiliated with a network.

One of the main advantages of HDHPs is that the premium cost (the amount a patient pays for insurance) is usually lower compared to other types of plans. Once the deductible is reached, an HDHP can provide significant health coverage, sometimes up to 100%.

Advantages of HDHPs.

1. The premium cost is usually low;

2. Ability to use an HSA to save for medical expenses.

Disadvantages of HDHPs:

1. High out-of-pocket costs prior to coverage;

2. Сhigh costs of medical services.

HSA (Health Savings Account) Insurance Policy

An HSA is a savings account that can be used in conjunction with an HDHP insurance plan. The money in this account can be used to pay for medical expenses and is tax-free.

An HSA is linked to a high deductible health plan (HDHP). Patients must have an HDHP in order to open an HSA.

Contributions can be made to an HSA up to a certain limit, and these contributions can be used to cover medical expenses. Money contributed to an HSA is deducted from the patient's total income for tax purposes.

Unused funds at the end of the year do not disappear, but are carried over to the next year. An HSA allows patients to save for the future and use the funds when they need them. HSA funds can be used to cover medical expenses, such as the cost of medications, doctor visits, equipment and more.

Some patients over age 55 can make additional contributions to an HSA, which can be beneficial in preparing for medical expenses in retirement. HSA funds can be spent at any time on medical expenses, even if the patient does not have high medical expenses during the year.

HSA benefits:

1. Tax-free savings on medical expenses;

2. Flexibility in the use of funds.

Disadvantages of HSAs:

1. an HDHP plan is required to use an HSA;

2. Limitations on the amount of annual contributions.

When choosing a health insurance plan in the United States, it is important to know the characteristics of each type and its ability to meet your specific needs. A thorough study of the terms of the insurance plan will help ensure reliable medical coverage under optimal financial conditions.