Health Insurance Policy Types and Benefits
Delivery models
Health plans differ in network rules and cost controls. Indemnity plans allow broad provider choice and often use deductibles and coinsurance. HMOs generally require a primary care physician and referrals, and typically cover only in-network care except emergencies. PPOs allow out-of-network care at higher cost and usually do not require referrals. POS plans combine HMO and PPO features. EPOs typically cover only the network. High-deductible health plans paired with health savings accounts require qualifying deductibles and limits; HSA contributions are tax-advantaged when eligibility rules are met.
Other coverage includes disability income, long-term care, critical illness, accident, dental, and vision. Disability income replaces part of earned income and defines disability as own-occupation or any-occupation. Long-term care covers custodial and personal care for chronic conditions. Critical illness pays a lump sum on diagnosis. Benefits may include hospital, surgical, physician, prescription, maternity, preventive, and mental health coverage; mental health parity rules limit differences in coverage.
Traps
Do not say PPOs require referrals. Do not say HMOs cover nonemergency out-of-network care routinely. HSA eligibility requires a qualifying HDHP and no disqualifying coverage. Own-occupation disability is broader than any-occupation.
Worked rule
A person covered by Medicare generally cannot contribute to an HSA, and a general-purpose health FSA can also disqualify HSA contributions. Always check the HDHP and HSA eligibility rules together.