The Tia Guide to Health Insurance

The Tia Take

Health insurance is confusing, to say the least. Don’t stress: we’re here with a breakdown of common plan types, costs to keep in mind, and a glossary of terms so you can cut through the noise and make the most empowered decisions about your health. At Tia, we're in-network with most commercial insurance plans — and we're here to help you get the most out of your benefits. Let's break it down, step by step.

Step 1: Let's Compare Health Plan Types: PPO, HMO & HDHP

It can seem like alphabet soup, but the differences between PPOs, HMOs and HDHP are crucial. Let’s break it down.

PPO (Preferred Provider Organization)

Do you have to stay in-network to get coverage?

No, but in-network care is less expensive*

Do procedures & specialists require a referral?

Overview

PPOs are all about choice. They prefer you see in-network providers (hence the name), but often have a large pool to choose from—and some have a tiered network that let you see an even wider group of providers, though the cost can vary depending on what preferred tier they’re in. PPOs also don’t require referrals to see specialists. The greater freedom to choose means PPO plans don’t have as much control in lowering healthcare spending, so often the premiums are pricier than HMO plans.

HMO (Health Maintenance Organization)

Do you have to stay in-network to get coverage?

Yes, except for emergencies*

Do procedures & specialists require a referral?

Yes, typically

Overview

An HMO is generally cheaper than a PPO, but you can only see specific doctors and specialists who are in-network. You’ll also need a referral if you’re seeing a specialist. The trade-off for fewer provider options? HMOs offer lower premiums.

HDHP (High Deductible Health Insurance Plan)

Do you have to stay in-network to get coverage?

No, but in-network care is less expensive*

Do procedures & specialists require a referral?

Yes, typically

Overview

An HDHP has a higher deductible than a typical health plan, but it also has lower premiums. They’re a little more complex than the rest, and the burden is on you to manage healthcare costs, but can be a good choice if you’re rarely sick or injured and can afford to pay the upfront costs if something unexpected happens. This is also the only plan that can be paired with a Health Savings Account (HSA), so you can save pre-tax money and spend it on health expenses.

*If you’re out-of-network with Tia, you can still be a cash-pay patient! Take a look at our service list and cash prices by city.

Step 2: Compare Out-of-Pocket Costs

Now that we’ve navigated all those letters, let’s tackle the numbers ($$$). During Open Enrollment, you will pick a health insurance plan that's right for you. There are cost trade-offs when it comes to picking plans, which is why it’s important to choose one that makes the most sense for your life. Do you go to the doctor often? You may want to pay higher monthly premiums for a plan with a lower deductible to ensure your health plan covers more of your costs sooner. Similarly, you might avoid the doc at all costs (but with our comprehensive care, cozy clinics, and virtual appointment flexibility, why would you?). In that case, you might be more comfortable with a higher deductible and a lower monthly premium. And let’s not forget changes to your health that might’ve impacted how often you use the doctor: yet another reason it’s important to know the ins and outs of your plan, reassess whether it’s working for you during Open Enrollment—and make the switch if it’s not.

Step 3: Know Your Terms

There’s a lot to digest when it comes to comparing insurance plans, so here’s a glossary of some need-to-know healthcare cost terms to make it easier:

Premium: Health insurance premiums are monthly (sometimes quarterly) payments you make to your health insurance provider to keep your coverage. When choosing a plan, you’ll see a range of premium costs; you’ll want to weigh the costs against the plan’s other benefits before deciding which one’s best for you.
Deductible: The annual amount of money you need to spend before your health plan begins to help cover your medical costs. Deductibles vary in price and coverage from one provider to the next, so it’s important to understand how your insurer applies your deductible ahead of any visit. For example, some plans might apply it to all medical services, while another might have separate deductibles for different services, like prescription drugs.

It’s also important to know that deductibles directly affect your premium costs. Low premiums means higher deductibles—and high premiums means lower deductibles. In short: if you go to the doctor frequently, you might choose a higher premium. While you’ll pay more monthly, your lower deductible means your health plan will cover more of your medical costs sooner.
Copays: Copayments (also called copays) are set fees you pay when you get healthcare service during a visit. These flat-rate fees vary by plan and service. For example, you might have a different copayment amount for primary care physicians vs. specialists vs. prescription drugs. You can usually find copay amounts on your insurance card or by calling your health insurance plan.
Coinsurance: For most plans, coinsurance is the percentage of the cost you must pay after you meet your plan’s deductible—typically a percentage of the overall medical service cost. For example, your coinsurance share might be 20% of a hospital visit, and your insurer would cover the remaining 80%. Health insurance plans with higher monthly premiums often have lower coinsurance percentages for patients.
Maximum Out-of-Pocket Costs: Just like the name implies, these are the maximum amount you pay out of pocket, per year, for medical services. This amount includes your copay + the coinsurance amount + the deductible itself. (It’s important to note these maximums don’t include premiums or out-of-network costs. Some plans have out-of-network maximums too, while others don’t put a cap on what you'll pay for out-of-network care.) Once you meet your maximum out-of-pocket amount, your health insurance company potentially takes over and covers any remaining balance.

For example, let’s use the 2023 maximums: $9,100 for individuals and $18,200 for families. Say you’re an individual with no medical expenses for most of the year who suddenly needs emergency hospital care. If your health insurance plan requires you to pay 20% of the hospital costs, but that amount exceeds the $9,100 out-of-pocket maximum, you’re only responsible for the $9,100. Your insurance company covers the rest.

Health Savings Accounts (HSA): A health savings account (HSA) is a savings account geared towards future medical expenses. Every year, you can decide how much money you want to put toward your HSA—and then you can use the money for deductibles, copays, and coinsurance. Your contributions are tax-free, and the balance rolls over from year to year. Because HSA funds are non-taxable when applied to the proper medical expenses, you can potentially reduce your tax burden. It’s important to note that HSA funds must be used to pay for qualified medical expenses, and premiums are typically not included as allowable costs.

Your Health Is Yours

There’s a lot to consider when understanding your health insurance and how your plan aligns with your financial priorities and your healthcare needs. If you’re in New York, California, or Arizona, Tia can be a great way to maximize your health insurance. Our mix of primary care, gynecology, wellness, and mental health helps make the most of your plan—and we’re in-network with most commercial insurance. Talk about a win-win.