Sandra was at her wit’s end. She had spent hours scrolling through health insurance options, trying to figure out which one made sense for her family. The sheer number of plans available in Dallas left her overwhelmed, and the technical terms didn’t help. Was an HMO better? Did she need an EPO? And what would all this really cost her in the end? Sandra felt stuck, unsure how to move forward, and worried she’d make the wrong choice during open enrollment.
If you’ve ever felt like Sandra, you’re not alone. Families all over Texas are having these same thoughts while shopping on the health insurance marketplace. Picking the right health insurance plan can feel like navigating a maze of options and unfamiliar jargon. But understanding the basics doesn’t have to be complicated. Let’s break down the key terms and choices that Sandra and other Texans focus on with the ACA plans available in Texas. But beyond what the key terms mean, Sandra learned how to compare options in a way that actually made sense for her.
The Two Types of ACA Plans in Texas: HMO and EPO
In Texas, ACA marketplace plans come in two varieties: HMO (Health Maintenance Organization) and EPO (Exclusive Provider Organization). Either type of plan offered by insurance companies has distinct features that cater to different needs, so understanding how they work is an important first step to comparing the various health coverage available.
HMO (Health Maintenance Organization): With an HMO plan, you must choose a Primary Care Physician (PCP) who acts as your main healthcare provider. Your PCP coordinates your care and refers you to specialists when needed. HMO plans require you to use doctors and hospitals within their provider networks, except in emergencies. This makes them a cost-effective option for people who don’t mind working within a structured system and working inside the network care that the health benefit plan uses.
EPO (Exclusive Provider Organization): EPO plans offer more flexibility compared to HMOs because you don’t need referrals to see specialists. However, like HMOs, EPOs only cover care provided by in-network services provided by doctors and facilities. They do include the same exceptions for emergencies though. These plans are a great choice if you want direct access to specialists without dealing with referrals but can stick to a specific provider network.
Sandra realized that her preference for fewer steps when seeing specialists might make an EPO a better fit for her family. But she also wanted to compare costs carefully, which led her to the next step.
Key Terms You Need to Know
Navigating health insurance often means understanding the language that comes with it. Sandra now understood that using in network care would be required, but trying to make sense of annual costs of the types of plans available seemed impossible. The health insurance marketplace plans used a lot of jargon that she didn't completely understand. For getting a handle on the cost of health insurance, Sandra needed to grasp some very key terms.
- Monthly Premium: This is the monthly health insurance cost you pay to maintain your plan, even if you don’t use any services. Most Texans are familiar with this term.
- Deductible: This is the amount you pay out-of-pocket for certain services before your insurance starts covering any portion of the costs for the medical services that you receive. Sandra, like many Texans was fixated on this number. You can continue to pay for additional health issues if you have not hit your max out of pocket for the year.
- Copay: A flat fee you pay for covered health care services, like a doctor visit or filling a prescription. These payments do not count towards your deductible or max out of pocket.
- Out-of-Pocket Maximum: This is the most you’ll pay in a year for covered health services, excluding copays. Once you hit this limit, your insurance covers 100% of additional costs for the rest of the year. This is why it is much more important than the deductible.
Understanding these terms helped Sandra feel more confident as she began comparing her options. She could see the difference between her monthly payments and what her total yearly costs could be if she had a major event that required a hospital visit, surgery, or extended care for a critical illness like cancer.
Comparing Plans by Total Cost of Risk
One of the biggest mistakes people make during open enrollment is focusing only on the monthly premium because it has a profound effect on their monthly budget. Since the COVID era premium tax credits are being removed, the premium subsidies that Texas families have enjoyed the last few years are now gone. That is making monthly payments for health insurance higher.
While Sandra was working with an experienced health insurance agent, she learned that looking beyond the monthly payment is important. She was introduced to the total cost of risk, which includes the premiums she will pay each month PLUS the maximum out-of-pocket costs she could face if something unexpected happens.
For example, Sandra compared two plans:
- Plan A: A lower premium of $350/month but a higher out-of-pocket maximum of $7,000.
- Plan B: A higher premium of $450/month but a lower out-of-pocket maximum of $4,000.
When she calculated the total cost of risk, Sandra realized that while Plan B had a higher monthly cost, it would save her money if her family needed significant medical care during the year. Plan B also had some cost-sharing reductions for copays as well. The extra $100 in monthly health insurance costs suddenly became worth it. Considering the worst-case scenario helped her make a more informed decision.
Matching a Plan to Your Needs
Choosing between an HMO or EPO depends on your healthcare needs and preferences. For someone like Sandra, who values flexibility and access to specialists, an EPO plan might be worth the slightly higher cost. On the other hand, HMOs are often a better fit for people who are comfortable working with a primary care doctor to coordinate their care and want to save on premiums.
If you have a family, it’s important to consider whether your preferred pediatricians or specialists are included in the network. Sandra made a list of her family’s most-used doctors and checked whether they were in-network for the plans she was considering. This simple step helped her rule out options that wouldn’t work for her.
Sandra also used the total cost of risk to help her nail down a Silver plan that included the essential health benefits that all ACA Marketplace plans have, but came with lower copays and deductible. She understood that her monthly cost was a little bit more, but she was protecting her family's savings account from being hit with major out of pocket expenses if she had to use her marketplace coverage.
Working with Insurance For Texans to Get an ACA Policy
Sandra felt more at ease when she reached out to Insurance For Texans for help. Instead of spending hours deciphering plans on her own, she worked with experts who could guide her step by step. They helped her compare HMO and EPO options and calculate the total cost of risk for each plan, ensuring she didn’t overlook any details. The better part is that the cost of health insurance was the same price even though she got personalized help.
The team at Insurance For Texans specializes in helping Texans navigate their health insurance options. They provided Sandra with personalized recommendations based on her family’s healthcare needs, budget, and provider preferences. Knowing she had professional support took the pressure off and helped her feel confident in her choice.
If you’re feeling overwhelmed like Sandra was, working with someone who understands the Texas ACA landscape can make all the difference. With expert guidance, you can choose a plan that fits your needs and gives you peace of mind.
Don’t let open enrollment leave you frustrated or confused. Click the button below to get expert help from Insurance For Texans and find the ACA policy that fits your needs for 2025!