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Coverage Options

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Understanding Insurance Types

When Looking at an Insuance Plan they are tipically broken into 4 plan types PPO, POS, HMO and EPO, here is a brief discription of those plan types.

PPO

Most flexible. You need not stay in-network for health care and do not have to use a PCP. You can go out of network for care, but you will receive less coverage.

POS

POS plans are hybrids of HMO and PPO plans. You must choose a PCP, can go out of network and still receive insurance coverage. Out-of-pocket expenses are substantially higher if you do not get referrals for non-network care.

HMO

Most restrictive. Requires you to choose a Primary Care Physician (PCP) from their provider networks. If you go out of network, you have to pay all medical costs

EPO

EPO plans are hybrids of HMO and PPO plans. You must choose a PCP, can go out of network and still receive insurance coverage. Out-of-pocket expenses are substantially higher if you do not get referrals for non-network care.

Coverage By the Numbers

Metal categories are based on how you and your plan split the costs of your health care. They have nothing to do with quality of care.

  • Platinum Plan Coverage 90% 90%
  • Gold Plan Coverage 80% 80%
  • Silver Plan Coverage 70% 70%
  • Bronze Plan Coverage 60% 60%

Platinum Plan

These plan have the most coverage and are the most expensive. Typically you do not need to meet your deductible for Primary Care and Specialist visits, Prescriptions and many tests. Primary care copays should be around $10-$20 each visit and Specialist are usually $20-$30 each visit. Deductible tend to be very low and your co-insurance is typically around 10%. With the Platinum plan your Maximum Out Of Pocket (MOOP) is also very low for each individual and as a family.

Gold Plan

These plan have very good coverage and are fairly expensive. Typically you do not need to meet your deductible for Primary Care and Specialist visits, Prescriptions and many tests. Primary care copays should be around $15-$25 a visit and Specialist are usually $20-$30 each visit. Deductible tend to be very low and your co-insurance is typically around 20%. With the Gold plan your Maximum Out Of Pocket (MOOP) is also fairly low for each individual and as a family.

Silver Plan

These plan have fairly good coverage and are moderately expensive. Typically you do not need to meet your deductible for Primary Care, Prescriptions and many tests. Primary care copays should be around $25-$35 a visit and Specialist are usually 35-$50 each visit. Deductible tend to be  fairly high and your co-insurance is typically around 30%. With the Silver plan your Maximum Out Of Pocket (MOOP) is also fairly high for each individual and as a family. IMPORTANT: If you qualify for “extra savings” on your deductible, copayment, and coinsurance (sometimes called “cost-sharing reductions”) you must pick a Silver plan to get the extra savings. You can save hundreds or even thousands of dollars per year if you use a lot of care.

Bronze Plan

These plan have minimal coverage and are fairly affordable. Typically you do need to meet your deductible before coverage begins for Primary Care and Specialist visits, Prescriptions coverage and many tests. Once you meet your deductible your Primary care copays should be around $35-$50 a visit and Specialist are usually $50-$75 each visit. Deductible tend to be very high around $7000 and your co-insurance is typically around 40%. With the Bronze plan your Maximum Out Of Pocket (MOOP) is also very high (around $7150) for each individual and as a family ($14300). If you have some medical or Prescription concerns these plans may not be a great option. Note: some companies will offer a couple of visits to a Primary care Doctor for a copay before deductible.