Not sure what ACA plan type is right for you? Here’s everything you need to know about HMOs, PPOs, EPOs, and POSs!
What are the different types of ACA plans?
There are 4 main types of Affordable Care Act, or ACA, health insurance plans:
- PPOs – or Preferred Provider Organization Plans
- POSs – or Point-Of-Service Plans
- HMOs – or Health Maintenance Organization Plans
- EPOs – or Exclusive Provider Organization Plans
Factors such as your budget, where you live, and the kind of health care you require are important to consider when choosing from ACA plans.
What do all the ACA plans have in common?
All ACA plans are mandated to cover 10 essential benefits. These 10 essential benefits include health care services such as:
- Emergency services
- Out-patient services
- Maternity and newborn care
- Mental health, behavioral health, and substance use disorder services
- Prescription Drugs
- Rehabilitative and habilitative services
- Laboratory services
- Pediatric services, including oral and vision care
- Preventative and wellness services and chronic disease management
According to Familiesusa.org, before the ACA’s essential health benefits, millions of people did not have coverage for maternity, substance use treatment, mental health care, or prescription drugs.
So long as you purchase an ACA plan, these 10 health care benefits will be covered in some shape or form. However, keep in mind that insurance companies are free to choose how they cover these benefits. This means, you may still have to meet a deductible, pay a copayment, etc…so always be sure to check plan details!
All ACA plans are all also eligible for government subsidies. If you buy a plan that is not ACA-compliant, you won’t be able to apply for subsidies. But keep in mind that you still may not get subsidies, even if you do choose an ACA plan. You can get subsidy estimates on eHealth while searching for plans, so you can have an idea of how much financial support you’ll be getting.
PPOs (Preferred Provider Organization Plans)
Preferred Provider Organization plans, also called PPOs, are one of the most popular plan types for individuals and families. PPOs allow you to visit whatever in-network health care provider you’d like without requiring a referral from a primary care provider.
In-network care will be covered at a higher benefit level than any care you receive out-of-network.
You can expect PPO plans to require you to pay an annual deductible before the insurance company kicks in. Additionally, you may also have a co-pay (according to eHealth, co-pays are usually around $10-$30) or coinsurance that you have to pay for certain health care services.
A PPO plan may be the right ACA plan for you if:
- You want to freedom to choose almost any medical facility or provider for your needs
- You want some coverage if you choose to go out-of-network
- You don’t want to have to receive a referral first from your primary care provider in order to see a specialist
HMOs (Health Maintenance Organization Plans)
HMO, or Health Maintenance Organization, plans offer a wide range of healthcare services through a network of providers who agree to supply these services to members. You’re likely to have coverage for a broad range of preventative healthcare services than you would through another plan.
As of 2018, HMOs have emerged as the most popular aca plan amongst eHealth shoppers. According to a recent study, 53% of shoppers selected an HMO plan in 2017.
You will be required to choose a primary care physician (PCP) who will take care of most of your health care needs. Your PCP will need to refer you to a specialist if you decide you want to see one.
While HMOs typically have lower out of pocket costs, you may be required to pay a deductible before your coverage starts but your co-pays will likely be minimal. Keep in mind that with an HMO you will likely have no coverage for any care you receive out-of-network or for services you receive without a proper referral from your PCP.
A HMO plan may be the right ACA plan for you if:
- You’re shopping for an ACA plan with a low monthly premium
- You want an ACA plan with little or no deductible and don’t mind having an out-of-pocket limit
- You need preventative care services
POSs (Point of Service Plans)
A Point of Service Plan, or POS, has some qualities of an HMO and PPO with benefit levels depending on if you receive care in or out-of-network. You can think of a POS plan as a sort of HMO/PPO hybrid.
Similar to an HMO plan, with a POS plan you will have to designate a PCP who will make referrals to in-network specialists when you require it. Typically services received through your PCP are typically not subject to a deductible or preventative care benefits are usually included.
Similar to a PPO plan, you may receive care from providers who are out of your provider network but with greater out of pocket costs. You may also be responsible for paying a co-pay, coinsurance, or an annual deductible.
A POS plan may be the right ACA plan for you if:
- You are willing to coordinate your care through your designated primary care physician
- Your preferred doctor participates within the plan network
EPOs (Exclusive Provider Organization Plans)
With an Exclusive Provider Organization plan, or EPO, you may exclusively use the care providers – this includes doctors, specialists, and hospitals – within the plan network, but you cannot go out-of-network and receive coverage.
An EPO plan may be the right ACA plan for you if:
- You do not want to have to get a referral to see a specialist
- Your preferred providers are in-network
- You want to receive a much lower negotiated monthly premium than what you would get with an HMO or a PPO plan