How to choose the right Marketplace health plan

There are several things to consider when you choose a health insurance plan for your specific healthcare needs and financial requirements. At a fundamental level, you will need to do three key steps:

• Compare the different types of health insurance plans on the Health Insurance Marketplace
• Look at a plan’s network  
• Weigh the costs and benefits of potential health plans

Evaluate the Four Health Insurance Plan Types

The plans available on the Health Insurance Marketplace will depend on your state, income, and other factors. There are four plan types you must evaluate:

• Health Maintenance Organization (HMO): A type of health insurance plan that typically limits coverage to services rendered by in-network medical providers. An HMO usually won’t cover out-of-network care except in emergencies.
• Exclusive Provider Organization (EPO): A managed care plan that only covers services from doctors, specialists, or hospitals within the plan’s network, except in emergencies. Generally, you won’t need to pick a primary care provider (PCP) or have a referral to see a specialist.
• Preferred Provider Organization (PPO): A flexible health insurance plan that permits you to visit either in-network or out-of-network providers; remember, in-network providers are more affordable. PPOs also allow you to see specialists without needing approval from a PCP.
• Point of Service (POS): A type of health insurance plan that requires you to select a PCP and get referrals to see specialties. POS plans also provide coverage for out-of-network care with a referral.

Look at a Plan’s Network

A potential health insurance plan will have a network of healthcare providers, from doctors and dentists to hospitals and urgent care clinics. An insurance company will partner with these healthcare providers and enter into contractual agreements where they agree to offer discounted service rates to that insurer’s members, thus joining the “network” of providers.

You receive in-network care when you visit a provider in your plan’s network. But, when you go outside of this network to receive care, it will be from what’s known as an out-of-network provider, which will most likely be more expensive. Out-of-network providers can charge you whatever rates they want since they aren’t in a contractual agreement with your health insurance plan.

As such, when you select a health plan, determine if having access to a larger network is essential. If you have strong relationships with your current medical providers, choose a plan that includes them within its network. Don’t hesitate to ask your doctors directly to find out if they are in the plan you are interested in.

Weigh the Costs and Benefits

Lastly, you must weigh the costs and benefits of a plan to determine if it is the right fit for you.

The main variables that will influence a plan’s costs include:

• Out-of-pocket maximum: The most you will have to pay for covered services in a plan year.
• Copayment or copay: The fixed amount you will pay for medical expenses.
• Coinsurance: The percentage of costs you pay for medical expenses often after you’ve met your deductible.
• Deductible: A deductible is the amount you will pay for covered healthcare services before the insurance company starts paying.  
• Premium: The monthly amount you pay for the health insurance plan. The higher the premium, the lower the out-of-pocket costs, and vice versa.  

Note: all Health Insurance Marketplace plans cover ten essential health benefits at no cost if delivered via a doctor or provider in your plan’s network.

Sometimes, a plan with higher costs is worth it because the plan’s benefits are comprehensive. For example, a more expensive plan might include coverage for physical therapy, telehealth, mental health care, etc. You will get a better idea of a potential health plan’s costs, benefits, and covered healthcare services by examining its Summary of Benefits and Coverage.