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Coverage Details

Networks

An HMO is a type of health insurance plan that requires members to use a network of approved doctors and hospitals, to see specialists or get certain treatment and needing a refferal. Out-of-network care is only covered in emergencies. HMOs generally offer lower premiums and out-of-pocket costs.

A PPO is a health insurance plan that offers more flexibility by allowing you to see any doctor or specialist, with or without a referral. You’ll pay less when you use providers within the plan’s network, but unlike an HMO, you can still get partial coverage for out-of-network care. PPOs typically have higher premiums and out-of-pocket costs, but they offer greater freedom in choosing healthcare providers.

An EPO is a health insurance plan that covers services only if you use doctors, specialists, or hospitals within the plan’s network—except in emergencies. Unlike an HMO, you don’t need a referral to see a specialist, but like an HMO, out-of-network care isn’t covered.

A POS plan is a hybrid health insurance option that combines features of HMOs and PPOs—you choose a primary care physician (PCP) and need referrals to see specialists, like an HMO. However, you can get care outside the network, similar to a PPO, though it usually costs more. POS plans offer moderate flexibility and costs, making them a middle-ground choice between strict network rules and higher-cost freedom.

Deductibles

A deductible is the amount you must pay out of pocket for healthcare services before your insurance starts to share the cost. For example, if your plan has a $1,000 deductible, you pay the first $1,000 of covered medical expenses yourself. After meeting your deductible, your insurance begins to cover a portion of costs, often through coinsurance or copays.

Out of pocket

An out-of-pocket maximum is the most you’ll have to pay for covered healthcare services in a plan year, including deductibles, copays, and coinsurance. Once you reach this limit, your health insurance covers 100% of covered services for the rest of the year. It protects you from very high medical costs by capping your total spending.

Copays

A copay (or copayment) is a fixed amount you pay for a covered healthcare service, usually at the time of the visit—like $25 for a doctor’s appointment. Copays can vary depending on the type of service (e.g., primary care, specialist, or emergency room). After you pay the copay, your insurance covers the rest of the allowed cost for that service.

Coinsurance

Coinsurance is the percentage of costs you pay for a covered healthcare service after you've met your deductible. For example, if your coinsurance is 20%, you pay 20% of the cost and your insurance pays 80%. Coinsurance continues until you reach your out-of-pocket maximum, after which your insurance covers 100% of covered services.

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About

Clients

  • Individuals & Families Without Employer Coverage

  • Clients on Marketplace Plans

  • People on Short-Term Health Plans

  • Early Retirees (Under 65)

  • Clients Paying High Premiums

  • People without Pre-Existing Conditions

  • Residents in Eligible States

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