Understanding your coverage options
Three letters — HMO, PPO, or something in between — decide how much you'll pay and which doctors you can see. Here's what actually matters before you choose.
Network types, explained plainly
PPO — Preferred Provider Organization
- No referral needed to see a specialist.
- Visit any in-network provider at a discounted rate.
- Out-of-network care is still covered, just at a higher cost to you.
- The most flexible network type — and generally the most expensive.
HMO — Health Maintenance Organization
- Care is coordinated through a primary care physician you choose.
- You'll usually need a referral before seeing a specialist.
- The in-network doctor and hospital list is smaller than a PPO's.
- Generally the least expensive network type.
POS — Point of Service
Works like an HMO — referrals required, primary care coordinated — but without the strict network limits. A POS plan will still pay part of a bill for non-emergency, out-of-network care. Priced between an HMO and a PPO.
EPO — Exclusive Provider Organization
Similar to an HMO in cost and network size, but without the referral requirement. You just need to stay within your EPO's specific provider list for non-emergency care.
How to enroll in a health plan
A straightforward sequence, whether you're doing it alone or with an agent's help.
Gather your information
Have your birthdate, home address, Social Security number, an estimate of household income for the year, and tax filing details on hand. If you're a legal immigrant, keep your documentation ready as well.
Assess what you actually need
Think honestly about how often you use care. If you have a doctor you want to keep seeing, confirm they're in-network before you commit — provider lists can be months out of date, so it's worth a direct call to the office.
Check your prescriptions
Make sure current medications and dosages are on the plan's approved formulary, and that you have affordable access to providers for any ongoing conditions.
Check subsidy eligibility
Depending on household income and size, you may qualify for ACA premium tax credits or cost-sharing reductions. Income thresholds are updated annually — an agent can check the current figures against your situation in a few minutes.