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Find Your Fit: What to consider when choosing a health plan
Find Your Fit: What to consider when choosing a health plan

Deciding on health coverage? Weigh the pros and cons of costs vs. access to care based on your different plan options to find your fit.

Updated over a week ago

3-minute read

As an employee, when open enrollment season arrives or when you first become eligible for benefits, understanding your options is crucial. The affordability of premiums and the breadth of provider access become a pivotal point of consideration when choosing a health plan.

Understanding your options

Employers tend to offer a variety of plans, including Preferred Provider Organization (PPO) plans, Health Maintenance Organization (HMO) plans, Exclusive Provider Organization (EPO) plans, and High Deductible Health Plans (HDHPs). Here’s a quick overview of each.

  • PPO Plans
    PPOs provide the flexibility of choosing providers both in and out-of-network, although out-of-network care comes with higher out-of-pocket costs.

  • HMO Plans
    HMOs typically incur lower premiums but require members to choose providers exclusively from within the network, except in emergency situations.

  • EPO Plans
    EPOs strike a middle ground by maintaining a smaller network but offering slightly more flexibility than HMOs since they usually do not mandate referrals for specialist visits.

  • HDHPs
    HDHPs offer a lower monthly premium than most traditional plans, but the trade-off is a higher annual deductible must be met before insurance starts contributing.

Weighing cost vs. access

HMO, EPO and HDHP plans can have a more restricted lineup of healthcare providers in contrast to the wide-ranging selection of PPO plans. So when it comes time to choose a plan, it’s important to evaluate your preferences, while contemplating common life scenarios that could impact your healthcare needs.

If you’re planning to expand your family, the availability and coverage of prenatal, childbirth, and pediatric services are critical. But it’s just as important to think about the plan’s coverage for other significant events, such as managing chronic conditions, unexpected surgeries, or specialized treatments like physical therapy. Certain plans may limit the choice of specialists and hospitals, which could be a considerable drawback if you require flexible access to various healthcare services.

It's also crucial to consider how you value the trade-off between paying lower monthly premiums and having less flexibility in choosing providers. This involves investigating whether the healthcare professionals and facilities you trust and frequent are part of the plan's network.

Consider the potential financial implications of seeking care outside the network. For instance, out-of-network care can lead to significantly higher out-of-pocket expenses, which could outweigh the savings gained from lower premiums. So, if you have specific health conditions that require specialized care, access to a broad range of specialists might be more important than immediate cost savings.

Choosing your plan

The choice between cost and care is highly personal and variable. It may be helpful to estimate your healthcare expenses for the coming year as best as you can, consider your medical history, and reflect on your current health status. Assessing these factors against the available plans will guide you toward a decision that best aligns with both your health needs and financial circumstances.

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