Choosing the right health plan can be confusing at times, but you are not alone. Get Covered Illinois has information to help you choose the best coverage for your needs and budget. You can also
find a trained professional in your community who can provide free help in person or on the phone.
There are different plan categories based on how you and the plan will share the costs of care. The category you choose affects how much your premium costs each month, the portion of costs your insurance company pays when you use your coverage, and your total out-of-pocket cost.
These amounts are averages and will vary from person to person. In general, the more you are willing to pay out-of-pocket for health care services, like doctor visits or prescription medications, the less you will pay for your monthly premium. The different categories do not mean that some plans are lower quality. All ACA Marketplace plans cover the10 Essential Health Benefits.
Things to Keep in Mind
- How often do you visit the doctor? If your health care needs are moderate, are you concerned about being able to pay for services for an unexpected illness or injury if your plan has high out-of-pocket costs?
- Do you have an illness or see the doctor often? If so, what costs are you comfortable paying out-of-pocket?
- Through the ACA Marketplace, most Illinois residents will qualify for financial help to lower monthly premium costs or reduce cost-sharing.
- Only Silver plans are eligible for financial help with cost-sharing, and sometimes this financial help makes the cost-sharing on the Silver plans lower than Gold or Platinum plans.
Depending on the type of plan you buy, your care may be covered only when you see a provider in your plan’s network. You may have to pay more or get a referral if you choose to get care from a provider that is not in your plan’s network.
A provider network is a specific list of the doctors, hospitals, pharmacies, and other health care providers that your plan covers. These providers are called network providers or in-network providers. A provider that your plan does not cover is called an out-of-network provider.
HMO (Health Maintenance Organization)
- With an HMO, you may have lower out-of-pocket costs than other plans.
- These plans generally will not pay for out-of-network services, or have limited out-of-network coverage, except in emergency situations.
- You will need to pick a regular doctor, called a primary care physician (PCP), who can refer you to see other doctors in your network, like in-network specialists.
POS (Point of Service)
- On average, POS plans have higher out-of-pocket costs than HMO plans.
- Like an HMO, you will need to pick a regular doctor, called a primary care physician (PCP), to help monitor your health care. However, you do not have to get permission before visiting other doctors in your plan’s network, like in-network specialists.
- POS plans give you the option of going out-of-network for services, but you will usually have to pay more.
PPO (Participating Provider Option)
- PPO plans often have higher out-of-pocket costs than other plans.
- Usually, you do not have to pick a regular doctor or get referral to see specialists.
- With a PPO plan, your insurance company will pay a portion of your out-of-network costs. This means you will have more freedom to choose doctors and hospitals regardless of network. However, you may pay more for services provided out-of-network.
Things to Keep in Mind
- Are your doctors and pharmacy in the plan’s network? Is your preferred hospital in the plan’s network?
- Where do you generally see the doctor? If you get health services in multiple places or travel often, does the plan cover out-of-network providers or have a national provider network?
- Will the plan require a referral to see a specialist or get other services? Do you prefer having one doctor who recommends other providers for your total health care?
There are two main types of costs you pay for health coverage:
- Monthly premiums – These are monthly payments you make to your insurance company even if you don’t get medical services
- Out-of-pocket expenses – This is what you pay each time you visit the doctor and is not covered or reimbursed by health
Most plans use a combination of these two payment types. In general, the more you are willing to pay out-of-pocket for health care services, like doctor visits or prescription medications, the less you will pay for your monthly premium
Things to Keep in Mind
- Consider the health care needs of your household when deciding which ACA Marketplace plan to buy. If you expect many doctor visits or regular prescriptions, you might want to consider a plan with lower out-of-pocket costs.
- When you complete an ACA Marketplace application, you can compare plans side-by-side based on price and other important features. You may qualify for financial help to lower your monthly premium or out-of-pocket costs.