From understanding a deductible in health insurance to in-network doctors, we’ll walk you through the basics of a U.S. employer-provided healthcare plan.
Deducti-what? The ultimate breakdown guide to US health insurance
If your employer provides health insurance, take advantage of the benefit—and get ready to do some serious homework. Job-based healthcare is built on a confusing maze of networks, expenses, and out-of-pocket costs. Head spinning? Don’t worry. We’re here to help.
What are the different types of health insurance plans?
Typically, employers offer at least one of these options:
HMO (Health maintenance organization)
An HMO is typically a more economical plan, but can also be the most restrictive. You’ll need to use in-network providers, and a primary care provider coordinates your care and makes referrals. Monthly premiums are typically low, and HMOs are usually zero-deductible health insurance. To make life easy, providers usually submit claims.
PPO (Preferred provider organization)
You may wonder: What is a PPO health insurance plan? This type of insurance offers maximum flexibility, but it will cost you. PPOs usually have higher monthly premiums, as well as larger deductibles. You’re free to see any provider (in- or out-of-network) without a referral, but you may have to pay out of pocket and submit your claim.
EPO (Exclusive provider organization)
An EPO mixes features of a PPO and HMO. With an EPO, you’ll have lower monthly premiums than a PPO, and you don’t need a PCP (primary care physician) to coordinate your care. However, you won’t be covered for visits out of network (except emergencies). Like an HMO, in-network providers and hospitals are covered, but, like a PPO, you can visit specialists with a referral.
POS (Point of service)
Another blended option, a POS allows you to see out-of-network providers, but it will cost more than in-network options. You’ll also need a PCP to coordinate your care. Costs tend to be higher than an HMO, but lower than a PPO.
What are the components of US healthcare?
Deductibles
Here are some of the most common benefits questions we hear:
- What is a deductible?
- What is a deductible with an example?
- How do health insurance deductibles work?
Deductibles can be confusing and a little intimidating.
A deductible is the amount of money you’ll pay before your health insurance coverage kicks in and pays for all or some of your medical expenses. Plans usually have one deductible amount for individuals and another for families. Need an example of how health deductibles work?
If your health plan includes a $1,000 deductible, you’ll have to pay that amount for any eligible charges. Once you hit that mark, your insurance will pay. Deductibles can be pricey. According to the Kaiser Family Foundation, in 2020, the average health insurance deductible was $3,722 for a family and $1,945 for an individual.
Premiums
A premium is what you pay for your health insurance every month. You’ll see it deducted from your paycheck on a pretax basis. You may wonder if health insurance premiums are tax deductible. That depends on your employment status and type of insurance. If your premiums are out-of-pocket, they may be deductible. However, you can’t deduct premiums that are taken out of your pretax dollars or your employer contributions.
Out-of-pocket maximums
Also known as out-of-pocket limits, this is the max you’ll pay on covered services in a year. Deductibles, copays, and coinsurance all count toward this limit, but your premiums will not.
In- and out-of-network providers
An in-network provider is a doctor, hospital, or clinic that accepts your insurance. They’re also called participating providers. An out-of-network provider does not contract with your insurance. If you see an out-of-network provider, you’ll have to pay the bill and, if allowed, submit a claim to your health insurance.
Frequently asked questions about healthcare plans
Ready, set, insure
When you’re signing up for health insurance, there’s a lot to think about. Take your time, read your materials closely, and make the choice that works best for you and your family. You’ll be a health insurance pro in no time.