How to Choose a Health Plan (Health Insurance for LGBTQ Folks Ep. 4)

In the fourth episode of our Health Insurance for LGBTQ People series, we explore different plan options including HMO, PPO, EPO, and POS plans, explain metal levels, and consider different criteria for choosing a health plan.

Time stamps:

1:08: The Three Cs of Plan Options

2:32: HMO plans

3:03: PPO plans

4:00: EPO plans

4:24: POS plans

4:56: HDHP-HSA plans (Check out hsastore.com/hsa-eligibility-list for more.)

7:02: Catastrophic plans

7:56: Short-term plans

8:46: Metal levels

(Example program eligibility chart source: https://ktla.com/business/press-releases/ein-presswire/732815868/understanding-the-texas-obamacare-subsidy-and-tax-credit/)

10:22: Other considerations for picking a plan

Transcript:

Introduction

PPO, HMO, EPO—why are there so many health insurance acronyms, and what do they all mean? Welcome back to another episode in our series on health insurance for LGBTQ folks.

Recap from Last Week

In last week's episode, we went through all the financial terms like deductible, copay, premium, and out-of-pocket max, so that in this episode, we can go through the plan options with a better understanding of the financial trade-offs involved.

If you haven't checked out that episode yet, I do recommend you go back and watch it first, since I'm just going to be cruising through those terms in this episode and focusing on defining these acronyms and understanding the metal levels.

Hopefully, by the end of this episode, you'll have a good understanding of all the different plan options and how to pick the one that's right for you. Let's get into it.

How to Choose a Plan: The Three C’s

First, let's talk about the different types of coverage. There are four main options: HMO, PPO, EPO, and POS.

Now, before I get into defining them, I want to go over how to choose which one works best for you. This is all about trade-offs—what I like to call the three C's of plan options. You've got:

• Cost

• Control

• Choice

Cost of Health Insurance Plans

So, cost is literally how much do you want to pay, and this will be both in terms of monthly premiums and cost sharing down the line (deductibles and out-of-pocket max). If you want to pay less, you are going to have a trade-off in terms of these other two options.

Control in Health Insurance Plans

Next is control. Some plans require you to have a primary care physician, who you see first for everything, and then they give you a referral to see a specialist when you need one. Other plans, you can schedule an appointment with any doctor anytime you want, and that gives you more flexibility and the control to take care of your health needs in the way that you see fit.

Choice within Health Insurance Plans

Finally, there's choice. Choice is about the size of the network. In some plans, you have to stay in network—otherwise they won't cover any of the costs of your healthcare. In other plans, you can go out of network. You can decide which doctor you like best, what lab is most convenient for you to visit when you need to get blood drawn, where you want to go to have imaging done.

Now it may still be more expensive if it's out of network, but the cost sharing is at least there.

So these are the trade-offs involved in figuring out how much you want to pay versus how much choice and control you want to be able to have with your own healthcare.

Defining the Plan Types

HMO (Health Maintenance Organization)

HMOs tend to be the most affordable because they have a very tight circle and might not give you much control. In general, with an HMO you'll need to have a primary care physician who gives you a referral before you can go see a specialist.

Also, as we saw in last week's episode when we were looking at summaries of benefits and coverage, HMOs tend to not cover any out-of-network care at all, so you will need to stay in network if you want to get coverage.

PPO (Preferred Provider Organization)

These tend to be the most expensive, but also offer you the most choice and control. Preferred Provider Organization means that they do have a pre-approved list of in-network providers, but it's okay for you to go outside of that list and see whoever you want.

So this affords you a lot of choice. If there's a doctor that you have a pre-existing relationship with and you want to keep working with them, or if there's a lab or pharmacy that's closer to your office and makes it really convenient for you to get care during your lunch break, this flexibility does come at a cost. But if that's really important to you, then it might be worth it.

EPO (Exclusive Provider Organization)

It's "exclusive" in the sense that it has a closed network of providers that you can choose from.

So this has low choice, like an HMO, but it tends to be a little more flexible in terms of not requiring you to see a PCP first—and in that sense it's a little like a PPO.

POS (Point of Service Plans)

These tend to be a little bit more affordable upfront but then have higher cost sharing down the line. These plans are also a blend of HMO and PPO in the sense that, in a POS plan, you can go wherever you want for care, but you probably need a referral first. So in this sense, it's like a PPO in that you can go out of network if you want, and it's like an HMO in that you need to have a relationship with a PCP first.

Other Plan Options

If you're looking at these plans and you still feel like the costs are unaffordable, first—remember that financial assistance is available. Make sure you put your income into the marketplace application to see if you qualify. And second, there are a couple other plan options that we haven't discussed yet.

High-Deductible Health Plan (HDHP) with an HSA

These plans, as the name implies, have a very high deductible. For 2025, this might be around $8,000. They do have a lower monthly premium, and then this super high deductible.

So these plans aren't great for people who have chronic health conditions that require them to go to the doctor frequently or take a lot of prescriptions. But if you're someone who doesn't utilize healthcare a lot, this might be a good option for you.

Health Savings Accounts have tax advantages because your contributions are pre-tax, so you don't have to pay income tax on whatever you contribute to your HSA. For 2025, the HSA contribution allowance is just over $4,000 for someone on an individual plan and $8,500 for someone on a family plan.

And you might be surprised actually how many things you can pay for with an HSA. While monthly premiums are not qualified expenses, basically everything else is: You can use your HSA to pay for your copays and coinsurance, any vision care—checkups, glasses, eye drops—even dental care like checkups and braces, feminine hygiene products, fertility treatment, pregnancy tests, neonatal care like breast milk and pumps, medical supplies like crutches or a walker, sunscreen, sleep aids, and so much more. So if you have the availability to sign up for an HSA, it might be a good idea.

But keep in mind that high-deductible health plans are really best for folks who don't have any chronic conditions, don't go to the doctor often, don't have any prescriptions that they need, and aren't expecting to access medical care.

Catastrophic Health Plans

These are available to folks under 30 who, again, don't really expect to have any healthcare needs for the year. Catastrophic plans have low monthly premiums but super high deductibles. The deductibles are equal to the maximum amount that an out-of-pocket max could be—so for 2025, this is just over $9,000.

Catastrophic plans have coverage for preventive services as required by the ACA, and then generally for you to go see your primary care physician up to three times in the year for an office visit.

Other than that, you're probably going to pay everything up until you reach your deductible/out-of-pocket max. So again, catastrophic plans are really only a good idea if you don't expect to access care much at all.

Short-Term Plans

If you lose coverage throughout the year, or you know you're going to have a gap in coverage, you might be tempted to sign up for a short-term health plan. One reason I don't recommend that is that they aren't regulated by the Affordable Care Act like other marketplace health plans—so there's really no telling what they're going to cover and how much coverage might cost you.

A better idea would be to go to healthcare.gov and see if you qualify for a special enrollment period so that you can get marketplace insurance anytime during the year, not just during open enrollment period.

Last thing I'll say about this is: if you need help figuring this out, go ahead and contact an assister. There are marketplace navigators who can help you understand if you qualify for a special enrollment period and help you find a plan that fits your budget and your needs.

Choosing Your Metal Level

Aside from the different coverage options that we talked about earlier, metal levels are the different cost-sharing options within those. The way the metal levels work is that the more you pay upfront as a monthly premium, the lower the cost-sharing will be down the line.

Bronze plans, for example, have the lowest monthly premiums but then cover about 60% of your care. So the deductible will be a little higher, the cost-sharing will be a little bit less generous, and the out-of-pocket maximum will be a little higher.

• Bronze plans cover about 60% of care.

• Silver plans tend to cover about 70% of care.

• Gold plans cover about 80% of care.

• Platinum plans cover about 90% of care.

Platinum plans cover about 90% of care. So there's going to be a super high monthly premium, but then your costs throughout the year are going to be really low, both in terms of reaching your deductible and then the cost-sharing and then reaching your out-of-pocket max.

So this is really your decision—how much you want to pay upfront, and then how much you want to have unexpected costs every time you go see the doctor. If you don't anticipate going to the doctor a lot, you might want to get a bronze plan. You'll have a low monthly premium, and then you hopefully won't have many costs other than that (since they would be pretty high).

However, if you are managing a chronic condition, go see the doctor a lot, have a really expensive prescription, it might make more sense to pay more as your monthly premium in a gold or platinum plan—and then your costs every time you go to the doctor will be super low.

Cost Sharing Reduction (CSR) for Silver Plans

If you make up to 250% of the federal poverty line, there's a second form of financial assistance in addition to the premium tax credits we already talked about that you also qualify for. This is called the Cost Sharing Reduction, and it's only available in silver plans. So this could help you decide which metal level to pick.

Source

I mentioned earlier that silver plans generally cover about 70% of costs. With the Cost Sharing Reduction:

• A Silver 94 plan covers 94% of your costs

• A Silver 87 plan covers 87% of costs

• A Silver 73 plan covers 73% of your costs

So, depending on your income and your household size, this could be a great option for you—even more cost-effective than choosing a bronze plan. These plans are generally identical aside from the cost-sharing reduction, so keep that in mind as you're browsing plans—that this could be available.

When Other Factors Matter

Aside from costs, there might be two other reasons that you choose one plan over another.

Your Preferred Doctor

The first is a doctor. Say you have a doctor you really like working with, or a facility that's just down the street that you like going to—you can actually search during the marketplace application process for a doctor or facility to make sure that the plan that you sign up for has that doctor or facility as in-network coverage. This will allow you to keep going where you want without paying for out-of-network care.

Necessary Benefits

The second is coverage for a specific benefit. So, as we saw last week when we looked at summaries of benefits and coverage, if you really want acupuncture, say, you'll want to check and make sure that your plan is going to cover that benefit before you sign up for health insurance and realize down the line that they don't cover that at all. So that might be an important criterion for choosing one health plan over another.

Wrap-Up

So in this episode, we looked at most of those criteria for how you would choose a health insurance plan. We looked at the three C's: cost, control, and choice. We talked about the different metal levels and how you could pick a plan based on your doctor being in-network.

But for some of us, there's one more criterion we haven't talked about yet—and that's coverage of gender affirming care. So in the next episode, we're going to dive deeper into plan contracts and figure out how we can see if a plan covers gender affirming care, what care they cover, and how to get access to that coverage.