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Health Care Reform:

Health Insurance & Affordable Care Act

kynect: Kentucky's Healthcare Connection

Plans and Costs continued...

Within the metal levels are different types of plans, including:

HMO (health maintenance organization): You can only get treated by doctors in the plan's network (except in a medical emergency). You pay the full cost of care if you use a health care provider outside the network. You also need a referral from your primary care doctor before seeing a specialist.

PPO (preferred provider organization): You can see doctors and go to a hospital outside of your plan’s network for an additional cost. You generally do not need a referral before seeing a specialist.

POS (point of service): You can see doctors and go to a hospital outside of your plan’s network at an additional cost. You also need a referral from your primary care doctor to see a specialist.

EPO (exclusive provider organization): You are limited to doctors and hospitals that are part of your plan’s network (except in a medical emergency), but you generally do not need a referral before going to a specialist.

Costs: Costs of plans on the Marketplace vary based on your age, the number of people in your family, where you live, and your tobacco use. They cannot charge you more because of your sex or a pre-existing health condition.

What to Know When Choosing a Plan

Co-pay, Coinsurance, Deductibles, and Premiums: In addition to your monthly premium, here are other insurance costs to consider as you choose a plan:

  • Co-pay: A set amount you’ll pay for a health care service, such as a doctor visit
  • Deductible: The amount you need to pay before your coverage kicks in
  • Coinsurance: The percentage of costs you’ll pay for a health care service, such as a doctor’s visit

Your Choice of Health Care Provider: If you would like to keep your current doctor, check to make sure she's in the network you choose. You will pay either all or some of the cost of your health care if you choose a doctor outside the network.

Prescription Drug Coverage: If you take drugs for an ongoing condition, check the plan’s coinsurance and copayment requirements. Also check whether the drug is on the plan’s list of covered medications, called the formulary.

Your age: If you are under 30 and are in good health, you may want to consider a plan with a lower premium, such as a catastrophic plan.

Pre-existing conditions: If you need regular care, consider how many doctor and specialist visits and tests you may need.

Benefits

What’s Covered: All approved plans in the state must cover the same package of benefits, called essential health benefits. They include:

  1. Outpatient services, such as doctor visits or tests done outside a hospital
  2. Emergency services
  3. Hospital stays
  4. Pregnancy and baby care
  5. Mental health and substance abuse services, including behavioral health treatment
  6. Prescription drugs, including generic and certain brand-name drugs
  7. Lab tests
  8. Rehabilitative services, such as those that help people recover from an accident or injury, and habilitative services, which help people with developmental issues.
  9. Preventive and wellness services, along with those that help people manage chronic conditions; these are covered at no additional cost.
  10. Services for children, including dental and eye care

 

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