Medical Protection


Types of Medical Plans

Depending on how many plans are offered in your area, you may find plans of any or all 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 referral for an additional cost.
Source: Healthcare.gov

What is an EPO plan?

EPO stands for "Exclusive Provider Organization" plan. As a member of an EPO, you can use the doctors and hospitals within the EPO network, but cannot go outside the network for care. There are no out-of-network benefits.

An EPO plan may be right for you if:

  • You do not want to get a referral to see a specialist
  • You want to receive a much lower negotiated rate with an EPO plan than you would with an HMO or PPO plan
Source: Eheathinsurance.com

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What is an HMO plan?

HMO means "Health Maintenance Organization." HMO plans offer a wide range of healthcare services through a network of providers who agree to supply services to members. With an HMO you'll likely have coverage for a broader range of preventive healthcare services than you would through another type of plan.

How does an HMO plan work?

As a member of an HMO, you'll be required to choose a primary care physician (PCP). Your PCP will take care of most of your healthcare needs. Before you can see a specialist, you'll need to obtain a referral from your PCP.
Though there are many variations, HMO plans typically enable members to have lower out-of-pocket healthcare expenses. You may not be required to pay a deductible before coverage starts and your co-payments will likely be minimal. You also typically won't have to submit any of your own claims to the insurance company. However, keep in mind that you'll likely have no coverage for services rendered by out-of-network providers or for services rendered without a proper referral from your PCP.

An HMO plan may be right for you if:

  • You're shopping for a plan with lower premiums
  • You want a plan without a deductible and don't mind having an out-of-pocket limit
  • You need preventive care services such as coverage for checkups and immunizations
Source: Eheathinsurance.com
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What is a POS plan?

A Point of Service (POS) plan has some of the qualities of HMO and PPO plans with benefit levels varying depending on whether you receive your care in or out of the health insurance company's network of providers.

How does a POS plan work?

POS plans combine elements of both HMO and PPO plans. Like an HMO plan, you may be required to designate a primary care physician who will then make referrals to network specialists when needed. Depending upon the plan, services rendered by your PCP are typically not subject to a deductible and preventive care benefits are usually included. Like a PPO plan, you may receive care from non-network providers but with greater out-of-pocket costs. You may also be responsible for co-payments, coinsurance and an annual deductible.

A POS plan may be right for you if:

  • You're willing to play by the rules and possibly coordinate your care through a primary care physician
  • Your favorite doctor already participates in the network (use our Doctor Finder tool to find out)
Source: Eheathinsurance.com
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What is a PPO plan?

PPO plans, or "Preferred Provider Organization" plans, are one of the most popular types of plans in the Individual and Family market. PPO plans allow you to visit whatever in-network physician or healthcare provider you wish without first requiring a referral from a primary care physician.

How does a PPO plan work?

As a member of a PPO plan, you'll be encouraged to use the insurance company's network of preferred doctors and you usually won't need to choose a primary care physician. No matter which healthcare provider you choose, in-network healthcare services will be covered at a higher benefit level than out-of-network services. It's important to check if your provider accepts your health plan so you receive the highest level of benefit coverage.
You will probably have an annual deductible to pay before the insurance company starts covering your medical bills. You may also have a co-payment of about $10 - $30 for certain services or be required to cover a certain percentage of the total charges for your medical bills.

A PPO plan may be right for you if:

  • You want the freedom to choose almost any medical facility or provider for your healthcare needs
  • You want a portion of out-of-network claims to be covered by your insurance company
  • You don't want to get referrals before visiting a specialist
Source: Eheathinsurance.com
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