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What to Expect: Understanding Health Insurance Coverage

With the passage of the Affordable Care Act, some aspects of health coverage have changed while others remain the same.


To determine the right health insurance coverage for you and your family, it is important to understand how health insurance meet different needs. Here is a brief explanation of the different types of coverage available to you.


Health Maintenance Organizations (HMOs) and Exclusive Provider Organizations (EPOs)

HMOs and EPOs may limit coverage to providers inside their networks. A network is a list of doctors, hospitals, and other health care providers that provide medical care to members of a specific health policy. If you use a doctor or facility that isn't in the HMO’s network, you may have to pay the full cost of the services provided.


HMO members usually have a primary care doctor and must get referrals to see specialists. This is generally not true for EPOs.


Preferred Provider Organizations (PPOs) and Point-of-Service plans (POS)

These insurance policies give you a choice of receiving care within or outside of a provider network. With a PPO or POS, you may use out-of-network providers and facilities, but you’ll have to pay more than if you use in-network ones. If you have a PPO policy, you can visit any doctor without a referral.


If you have a POS policy, you can visit any in-network provider without a referral, but you’ll need one to visit a provider out-of-network.


High Deductible Health Coverage (HDHP)

High Deductible Health policies typically feature lower premiums and have a higher deductibles than a typical health insurance policy. As of 2016, HDHPs are policies with a minimum deductible of $1300 per year for individual coverage and $2600 for family coverage.


If you have an HDHP, you can use a health savings account or a health reimbursement arrangement to pay for qualified out-of-pocket medical costs. This can lower the amount of federal tax you owe.


Catastrophic Health Insurance

Catastrophic health insurance covers essential health benefits but has a very high deductible. This means it provides a kind of "safety net" coverage in case you have an accident or serious illness. Catastrophic policies usually do not provide coverage for services like prescription drugs or shots. Premiums for catastrophic policies may be lower than traditional health insurance coverage, but deductibles are usually much higher. This means you must pay thousands of dollars out-of-pocket before full coverage kicks in.


To qualify for a catastrophic plan, you must be under the age of 30 or qualify for a hardship exemption.  A hardship exception is a determination that you're unable to afford health coverage by the Market Place. Marketplace catastrophic policies cover three annual primary care visits and preventive services at no cost. After the deductible is met, they cover the same set of essential health benefits that other Marketplace policies offer. People with catastrophic coverage are not eligible for lower costs on their monthly premiums or out-of-pocket costs.


For more information about the different options visit


There are pro’s and con’s for each option. It’s important to select the right option based on your needs. Contact us for guidance in selecting the right policy for you and your family. There is no cost to you for our help.


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