Types of Health Insurance Plans

Health insurance plans are private (also called commercial) or public (government-funded). Most people in the US have health insurance through their employer.

If you don’t have insurance through your employer, you can also see if you’re eligible for government-funded insurance. Your state’s Marketplace decides if you qualify for financial help for insurance coverage.

• What is a managed care plan?
• High-deductible health plans and health savings accounts
• What you need to know about your insurance
• Things to know about your insurance if you have cancer

What is a managed care plan?

A managed care plan is an agreement between health insurance companies and health care systems and providers. Providers and facilities that have these agreements are “in-network.” If you have a managed care plan, health services with in-network providers are usually less expensive. You might have to pay more or all your medical bill if you get care outside your network.

When you’re looking for insurance, you might notice one of the following in the plan name:

• Health Maintenance Organizations (HMOs)
• Preferred Provider Organizations (PPOs)
• Point-of-Service (POS) Plans
• Exclusive Provider Organizations (EPOs)

HMOs, PPOs, POS plans, and EPOs are all kinds of managed care plans.

Here are some of the differences between managed care plans

Health maintenance organizations (HMOs) offer lower monthly premiums and out-of-pocket costs. However, they are less flexible with a smaller network of providers to choose from. They usually don’t cover out-of-network providers except for medical emergencies. You might also need a referral from your primary care provider before you can see a specialist.

Preferred provider organizations (PPOs) usually have higher premiums and out-of-pocket costs. But they’re typically more flexible with a larger network of providers to choose from. They may partially cover out-of-network visits but with higher copayment and coinsurance compared to in-network visits. And with a PPO, you might not need a referral from your primary care provider to see a specialist.

Point-of-Service (POS) plans are a hybrid of HMO and PPOs. Premiums are usually more than an HMO but less than a PPO. There is some flexibility with a larger network of providers (like PPOs), but usually require a referral from your primary care provider to see a specialist (like HMOs).

Exclusive Providers Organizations (EPOs) have some flexibility and cost less than most PPOs. You don’t need a referral from your primary care provider to see a specialist, but you can go out-of-network, except for emergencies.

High-deductible health plans and health savings accounts

High-deductible health plans (HDHPs) have lower monthly payments but higher deductibles. Some HDHPs come with the choice to sign up for a Health Savings Account (HSA). HSA funds come from your salary and are tax-free. But you can only use this money for certain qualified medical expenses.

What you need to know about your insurance

Whether you’re starting to look at your insurance options or you already have health insurance, it’s important to know what your plan does and does not cover.

Here are some things to think about:

• Even though the federal government doesn’t require you to have health insurance anymore, some states still do. Check your state's insurance requirements at healthinsurance.org.
• Premium tax credits are available only for Marketplace plans, not non-Marketplace plans.
• Non-Marketplace plans covering children might allow adult children to stay covered up to age 26 (just like Marketplace plans).
• Is the plan a Qualified Health Plan?
• Are the health care providers, specialists, and pharmacy you want to use in your network?
• Are the medicines you take or will take covered? Look for a formulary list. This is a list of all the medications your pharmacy benefits cover.
• Does your insurance require pre-approval for certain tests, procedures, or treatments (also called prior authorization)?
• Are any services not covered?

Things to know about your insurance if you have cancer

If you have cancer, it’s important to understand your health insurance’s Summary of Plan Benefits (SPB) to understand covered and excluded services.

Many insurance companies require pre-authorization for cancer services. Here are some things you might want to check your insurance coverage for:

• Cancer tests such as PET/CT scans, blood tests, bone scans, and other procedures.
• Inpatient and outpatient care including screening, tests, and treatment.
• Cancer therapies such as chemotherapy, radiation, or outpatient infusion) and clinical trials.
• Routine cancer screening or diagnostic test coverage might be different depending on if they are considered “routine” versus “diagnostic.”
• Genetic screening or testing to check your cancer risk or find the best treatment.
• Medical equipment such as a cane, walker, hospital bed, or lymphedema supplies (also called Durable Medical Equipment or DME).
• Disposable Medical Supplies like gloves, needles, saline flushes, or dressing kits. Health insurance plans might have different coverage for disposable supplies than for DME.
• Wigs may be covered if your doctor writes a prescription for a “cranial or hair prostheses.”
• Nutritional supplies such as nutritional supplements or feeding supplies.

Need more information?

Along with the American Cancer Society, other sources of information and support are:

US Department of Health and Human Services, State Health Marketplaces & more
Toll-free number: 1-800-318-2596 (also in Spanish)
TTY: 1-855-889-4325
Website: www.healthcare.gov

Provides information on the new insurance law, takes you through the steps of finding insurance, and much more. If you don’t have Internet access, the phone number will help you connect with your state’s Marketplace to sign up for a plan

You can learn about hardship exemptions (which allow some people to avoid the penalty for not having health insurance)

US Department of Health and Human Services

Medicaid
Toll-free number: 1-877-696-6775
Website: www.medicaid.gov/index.html

Medicare
Toll-free number: 1-800-633-4227
TTY: 1-877-486-2048
Website: www.medicare.gov

Your state social service or human service agency can give you the best answers to questions about your benefits, eligibility, and fraud.

Answers questions, provides literature, and gives referrals to state Medicare offices and local HMO’s with Medicare contracts.

Department of Veterans Affairs
Toll-free number: 1-800-827-1000
Website: www.va.gov

For information on Veteran’s medical benefits and whether you qualify for them
Toll-free number: 1-877-222-8387
Website: www.va.gov/healthbenefits/apply/veterans.asp

*Inclusion on these lists does not imply endorsement by the American Cancer Society.