Health insurance in the United States has different types of plans to meet the different needs and financial capabilities of an individual or family. Learn more about the main types of health insurance plans and their characteristics

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Health insurance in the United States of America is diverse and can include different types of plans such as HMO, PPO, EPO, POS, HDHP, and HSA. Each of these plans has its own features and benefits designed for different needs and requirements of policyholders. Let's take a look at their detailed characteristics.

HMO (Health Maintenance Organization) insurance policy

A HMO is a healthcare system that unites the insurer, providers, and patients into a single network. The main idea is to limit the patient outside the network to ensure coordinated and affordable health care. A referral from a doctor may be required to use out-of-network services.

An HMO combines an insurer, doctors, hospitals, and other healthcare providers into a single network. Patients choose a Primary Care Physician (PCP) from the network to coordinate their care.

To receive specialized care, patients often need a referral from their PCP. This ensures coordinated and efficient care.

HMO's usually have a low premium cost compared to other types of insurance plans. However, patients may incur additional costs when visiting doctors outside the network.

Patients are required to receive medical services in the HMO network. The choice of doctors and hospitals outside the network may be limited or non-existent.

Most often, the HMO sets a co-payment (fixed fee for the service) or co-payments for visits to the doctor. There is a high probability that most medical services will be fully or partially covered by insurance.

HMO's emphasize preventive health care and a healthy lifestyle. Regular medical checkups and preventive measures are usually covered by the insurance plan.

Advantages of HMO's:

1. Usually low premium cost;

2. High level of coordinated medical care.

Disadvantages of HMO's:

1. Limited choice of doctors and hospitals;

2. A referral is required for out-of-network consultations.

PPO (Preferred Provider Organization) insurance policy

A PPO is a type of insurance plan that provides a greater choice of doctors and hospitals if they are in the "preferred" network. Patients can also receive medical services outside the network, but at less favorable conditions.

PPO also has its own network of doctors and hospitals, but it is less limited than HMO. Patients can receive medical services outside the network, but at reduced rates within the network.

A distinctive feature of PPO is that patients are not required to receive referrals for consultations with specialists. They can directly contact specialists without wasting time on getting referrals.

PPO's usually have lower co-payments and deductibles for in-network healthcare services. Patients usually pay less for medical services in the network. If a patient chooses to receive healthcare services outside the network, the cost will be higher, but it may still be an acceptable discount.

The difference between PPO is that patients can receive medical services without choosing a primary care physician. There is no need for referrals for specialized consultations. PPO provides more flexibility in choosing medical providers and does not require referrals for many services.

Advantages of PPO:

1. Wider choice of doctors and hospitals;

2. No referral required for out-of-network consultations.

Disadvantages of PPO:

1. Higher premium cost compared to HMO;

2. The cost of out-of-network services may be higher.

EPO (Exclusive Provider Organization) insurance policy

EPO is a combination of HMO and PPO elements. Doctors and hospitals must be in-network, but patients can receive some services outside the network without a referral.

An EPO also has a network of doctors and hospitals, but it can be more limited compared to a PPO, similar to an HMO. Patients can receive medical services outside the network, but this is usually not covered by the insurance plan.

The peculiarity of EPO is that many medical services do not require referrals from a primary care physician. Patients can see specialists on their own without prior approval.

The EPO network usually has lower co-payments and deductibles for medical services compared to services outside the network. Patients pay less for in-network visits and procedures.

The EPO does not provide out-of-network coverage (except in situations of medical emergency or other exceptional circumstances). If a patient chooses to receive medical services outside the network, he or she is usually not covered. Compared to an HMO, an EPO may not require you to choose a primary care physician or referrals for specialist consultations. An EPO offers the flexibility of choosing medical providers within the network without the need for referrals.

Benefits of EPO:

1. Usually lower premium cost than PPO;

2. Choice of doctors and hospitals in the network.

Disadvantages of EPO:

1. You cannot get all services outside the network without a referral;

2. Limited choice compared to PPO.

POS (Point of Service) insurance policy

POS is a flexible plan that combines the features of HMO and PPO. Patients can choose in-network doctors and hospitals or receive out-of-network services for an additional cost.

A POS has its own network of doctors and hospitals. If a patient receives medical services in the network, they are usually covered by the insurance plan.

For specialized medical services, a referral from a primary care physician may be required. Patients should choose a primary care physician to coordinate their care. If the patient chooses to receive medical services outside the network, the cost may be higher, but the cost is partially covered by the insurance plan.

Usually, POS allows patients to see specialists without referrals. Flexibility to choose out-of-network providers. If the patient receives medical services outside the network, he or she may pay additional costs, such as co-payments and deductibles. In the case of emergency medical care, POS can cover services even outside the network, providing patients with more flexibility.

Benefits of POS:

1. Wider choice of doctors and hospitals;

2. Ability to receive services outside the network.

Disadvantages of POS:

1. Usually higher premium cost compared to HMO's;

2. Requires a referral for specialized services.

HDHP (High Deductible Health Plan)

An HDHP is a plan with a high level of out-of-pocket costs, where the patient has a large additional cost before the insurance begins to cover the costs. This type of plan is usually used in conjunction with a health savings account (HSA).

HDHPs have a high deductible, which is the amount a patient must pay before the insurance begins to cover the cost. HDHP patients pay most of their medical expenses until they reach the deductible. HDHPs can incentivize patients to be prudent about their health and manage their medical expenses effectively.

Many HDHPs are linked to a Health Savings Account (HSA), which allows patients to save money for medical expenses with tax benefits. HDHP patients can often choose the doctors of their choice, as they are not necessarily affiliated with a network.

One of the main advantages of HDHPs is that the cost of the premium (the amount a patient pays for insurance) is usually lower compared to other types of plans. Once a deductible is reached, an HDHP can provide significant healthcare coverage, sometimes as much as 100%.

Advantages of HDHPs:

1. Usually low premium cost;

2. Ability to use an HSA to save for medical expenses.

Disadvantages of HDHPs:

1. High out-of-pocket costs before coverage;

2. High costs for medical services.

HSA (Health Savings Account) insurance policy

An HSA is a savings account that can be used in conjunction with an HDHP insurance plan. The money in this account can be used to pay for medical expenses and is tax-free.

An HSA is linked to a high-deductible health plan (HDHP). Patients must have an HDHP in order to be eligible to open an HSA.

Contributions to an HSA can be made up to a certain limit, and these contributions can be used to cover medical expenses. Money contributed to an HSA is deducted from the patient's total income for tax purposes.

Unused funds at the end of the year do not disappear, but are carried over to the next year. An HSA allows patients to save for the future and use the funds when they need them. HSA funds can be used to cover medical expenses, including the cost of medicines, medical consultations, equipment, and more.

Some patients over the age of 55 can make additional contributions to an HSA, which can be beneficial for preparing for medical expenses in retirement. HSA funds can be spent at any time on medical expenses, even if the patient does not have high medical expenses during the year.

Benefits of HSA:

1. Tax-free savings on medical expenses;

2. Flexibility in the use of funds.

HSA disadvantages:

1. An HDHP plan is required to use an HSA;

2. Limitations on the amount of contributions annually.

When choosing a health insurance plan in the United States, it is important to understand the features of each type and its ability to meet your specific needs. Careful study of the terms of the insurance plan will help ensure reliable medical coverage at optimal financial conditions.

Daria Rogova, Head of Insurance at Visit World

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Products from Visit World for a comfortable trip:

Checklist for obtaining a visa and necessary documents in the United States;

Legal advice on business issues in the United States;

Travel insurance for foreigners in the United States;

Medical insurance around the world.

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