The different plans available to you can vary in structure, cost, and flexibility.
First let’s talk about Preferred Provider Organizations, or PPO plans. These plans come with both in and out of network benefits, with the richest benefits being provided when you seek in network care. We talked about in and out network benefits in episode 4, so check out that video if you need a refresher! PPO plans allow you to seek care at any doctor or medical facility and you don’t need referrals from your primary care provider to seek care from a specialist. This flexibility often translates to higher monthly premiums.
Exclusive Provider Organizations, or EPOs only offer benefits if you stay in-network. There are NO benefits for out-of-network care except for emergency care. You don’t need referrals from your PCP to seek care from specialists on an EPO plan. EPOs are typically less expensive than PPO plans.
Then there are Health Maintenance Organizations, or HMO plans. Just like an EPO, there are no benefits if you seek care out of network unless you’re seeking emergency care. One added restriction of an HMO is that all of your care starts with your primary care provider and you need referrals to see specialists. HMOs tend to emphasize preventative care and have affordable monthly premiums.
There are also Point-of-Service plans, which still require you to have a primary care provider and obtain referrals to see specialists, but there are benefits if you go out of network (although the benefits aren’t as rich as if you stay in-network).
Those are the four different structures of health insurance plans, but there can be other differences as well. For example, you may have any one of the aforementioned plans in the form of a High Deductible Health Plan. These plans have higher deductibles and lower monthly premiums, and often provide you with eligibility to open a Health Savings Account. Health Savings Accounts are special tax-advantaged savings accounts that allow you to save and invest funds to be spent on eligible medical expenses (more on HSAs in another episode).
You may have also heard of short-term plans, which are super affordable but offer very limited coverage. These plans have not been available in Washington state since 2022 (as of 2025 when this video is being made).
Then of course, there is Medicare, which is a federal program for people age 65+ or those who meet other eligibility criteria. If you want to learn about Medicare, watch our Medicare101 series.
And finally, Medicaid, which is called Apple Health in Washington state and is a joint federal and state program for low-income individuals. It is free or very low cost and offers a very high level of coverage, but there is some limitation regarding medical provider access.
