Health Insurance Basics

POS: Point of Service

POS plans are another hybrid of HMO and PPO plans. You’ll have a primary care provider on an HMO-style network that can coordinate your care. You’ll also have access to a PPO-style network with out-of-network options (albeit at a higher cost). The HMO network will be more affordable, and you will need to get a referral to see HMO specialists.

POS plans typically have more expensive premiums than pure HMOs, but less expensive premiums than PPOs.

Learn more about the differences between HMOs, PPOs, EPOs, and POS plans.

What are the metal tiers?

Remember earlier when we talked about how all health insurance plans split some of the costs between the insurer and the consumer? Metal tiers are a quick way to categorize plans based on what that split is.

Some people get confused because they think metal tiers describe the quality of the plan or the quality of the service they’ll receive, which isn’t true.

Here’s how health insurance plans roughly split the costs, organized by metal tier:

  • Bronze – 40% consumer / 60% insurer
  • Silver – 30% consumer / 70% insurer
  • Gold – 20% consumer / 80% insurer
  • Platinum – 10% consumer / 90% insurer

These are high-level numbers across the entirety of the plan, taking into account the deductible, coinsurance, and copayments, as dictated by the specific structure of the plan, based on the expected average use of the plan. These percentages do not take premiums into account. They also do not represent the exact amount that you’ll actually pay for medical services.

In general, Bronze plans have the lowest monthly premiums and Platinum plans have the highest, with Silver and Gold occupying the price points in between. As you can see from the cost-sharing split above, Bronze plan premiums are cheaper because the consumer pays more out of pocket for health care services. If you frequently utilize health care services, you’ll probably end up paying more out-of-pocket if you choose a Bronze plan, even though it has a lower premium.

If you qualify, you can use a health insurance premium subsidy to help you afford a plan in a higher tier, ultimately saving you money.

There’s a fifth category of health insurance plans that you may see on the marketplace, called “catastrophic” plans. Catastrophic plans have very high deductibles — often, the deductible is the same as the out-of-pocket max — which means they’re really only useful for preventing an accident or serious illness from causing you to go into severe debt. Catastrophic plans are only available for people under 30 or people with a hardship exemption. You cannot use a subsidy on catastrophic plan premiums, but, for years during which the health insurance mandate was active, catastrophic plans did count as qualifying health care.

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